f 


This  booV  is  DI'T  >'      '•> 


SOUTHERN  BRANCH; 

UNIVERSITY  OF  CALIFORNIA, 

LIBRARY, 

LOS  ANGELES,  CALIF. 


MANUAL  OF  PHYSIO-THERAPEUTICS 


©pinions  of  tfirst  Boition 

"  The  author  has  endeaVoured  to  embody  the  chief  points  of  interest 
and  importance  briefly  and  succinctly  in  such  a  manner  as  to  awaken 
interest  and  lead  to  further  study.  .  .  .  We  can  give  all  praise  to  Dr.  Luke's 
work.  ...  It  is  perhaps  doubtful  whether  the  proper  application  of 
these  subjects  is  fully  appreciated  by  general  practitioners,  and  a  volume 
of  this  kind  will  be  welcomed.  .  .  .  The  illustrations  are  numerous  ajld 
good.  .  .  .  Those  who  wjsh  to  increase  their  knowledge  of  mechanical 
therapeutics  cannot  do  better  than  consult  its  pages." — Lancet. 

"Deals  fully  and  professionally  with  methods  of  treatment  other  than 
by  drugs.  ...  A  book  that  will  be  most  useful  to  all  medical  men,  espe- 
cially to  general  practitioners  and  to  consulting  physicians.  The  letter- 
press in  itself  is  clear  and  interesting,  and  it  is  made  the  more  so  by  the 
many  illustrations.  .  .  .  Gives  perfectly  clear  accounts  of  hydrothera- 
peutics,  electro-therapeutics,  and  so  forth,  in  a  general  way,  and  also  of 
each  different  process  that  may  be  required." — Hospital. 

"It  is  very  rarely  we  have  felt  called  to  so  warmly  welcome  a  book  as 
this.  The  hackneyed  phrase  about  supplying  a  long-felt  want  is  literally 
true  here,  as  we  know  of  no  other  covering  the  same  ground  in  anything 
like  the  same  way.  It  is  a  book,  and  the  only  one  we  know  of,  to  drive 
home  to  the  general  practitioner  the  raison  d'etre  of  physiological  and 
physical  methods,  to  give  him  intelligent  guidance  as  to  what  patients  he 
ought  to  put  under  such  methods,  and  to  enable  him  to  properly  instruct 
the  layman  to  whom  he  delegates  the  carrying  out  of  these  methods.  We 
regard  it  as  most  unfortunate  for  a  medical  attendant  to  have  to  hand 
over  blindly  a  patient,  entirely  trusting  to  a  lay  operator.  We  fear  some 
have  to  do  it.  If  they  read  this  book,  they  need  not.  It  is  pleasantly 
written,  well  got  up,  and  beautifully  illustrated. — South  African  Medical 
.Record. 

"  Medical  men  interested  in  the  question  of  physical  therapy  should 
find  much  educative  material  in  Dr.  Luke's  manual.  .  .  .  The  value  and 
attractiveness  of  the  book  are  added  to  by  the  many  illustrations  of  the 
processes  and  mechanical  devices  employed." — Scotsman. 

"  Intended  primarily  for  the  medical  faculty,  it  ought  to  be  of  interest 
to  many  others,  and  these  not  only  the  people  who  suffer  from  the  diseases 
here  dealt  with,  but  those  who  will  be  attracted  by  his  historical  examina- 
tion of  the  subject  from  the  earliest  times." — Newcastle  Chronicle. 

"  An  up-to-date  resume  of  the  modern  treatment  by  hydrotherapy 
with  and  without  the  additional  assistance  of  heat,  light,  massage,  and 
electricity  ...  is  profusely  illustrated." — Western  Daily  Press. 


MANUAL    OF 
PHYSIO-THERAPEUTICS 


BY 


THOMAS    DAVEY    LUKE 

M.D.,   F.R  C.S.  En. 


WITH     MANY     ILLUSTRATIONS 
NEW    AND    REVISED    EDITION 


''Would  you  have  us  plare  reliancr 
l.ess  in  drugs  and  pseuclo  science'- 
More  in    Nature  :  for  our   ills 
Using  sense  and  fewer   Pills ': 
Mo — the  change  were  all  too  tragic  . 
Most   folks  like  Leing  healed  l,y   Magic. 

A.\-o> 


NEW    YORK 
WILLIAM    WOOD    AND    COMPANY 

MDCCCCXXII 


PRINTED 


(;UKAT   BRITAIN 


Dedicated  to 
SIR   HUMPHRY   DAVY   ROLLESTON. 

K.C.B.,    M.D.,    F.R.C.P., 

CONSULTING    PHYSICIAN,    ST.    GEORGE'S    HOSPITAL,    W.   ; 
LATELY   SURGEON    REAR-ADMIRAL,    R.X. , 

WITH    PLEASANT    MEMOEIES    OF    ASSOCIATED    WORK 
IN    THE    GREAT    WAR 


PREFACE 

*0 

N    SOME  twelve  years  have  elapsed   since  the  first  edition  of 
this  work  was  passing  through  the  press,  and  during  that 
time  enormous  strides  have  taken  place  in  physio-thera- 
peutics.    The  scope  of  treatment  at  our  leading  spas  has 
greatly  widened,  and  on  the  whole  the  drinking  of  mineral 
i      waters — some  with  a  very  nasty  taste  ! — now  takes  second 
^"  place  to  bathing  and  douching  and  the  various  other  methods 
of  physical  treatment. 

In  all  departments  of  medicine  the  experience  of  the  war 
has  caused  a  great  advance,  but  in  no  section  has  it  been 
greater  than  in  physio-therapeutics.      Treatment  stations 
^N   established   throughout   the   country   for   the   cure   of   the 
wounded  are  now  continued  for  the  further  treatment  of 
^  ex-soldiers    under    the    Ministry    of    Pensions.      Massage, 
'  electricity,  and   the   other   methods   associated  with  them, 
have  ceased  to  be  the  monopoly  of  the  idle  rich  and  valetu- 
dinarian;  their  value  is  recognized  by  the  working  classes 
and  has  been  demonstrated  to  them  not  once,  but  on  many 
thousands  of  occasions. 

The  author  was  highly  gratified  by  the  favourable  recep- 
tion afforded  this  work  when  it  first  appeared,  but  is  now 
confident  that  there  is  a  much  larger  field  for  it  and  a  larger 
circle  of  readers.  Several  sections  have  been  entirely 
rewritten,  all  have  been  brought  up  to  date,  and  an  entirely 
new  one  added  on  physical  training  based  on  the  Bruce 
Sutherland  system.  The  author  would  here  express  his 
cordial  thanks  to  Mr.  Bruce  Sutherland  for  his  great  help  in 


viii  PREFACE 

this  matter,  and  the  loan  of  many  most  excellent  figures 
which  most  effectively  illustrate  the  text ;  and  also  to  Messrs. 
T.  Nelson  and  Son,  his  publishers. 

My  thanks  further  are  due  to  Mr.  A.  Dickson  for  valuable 
help  on  technical  points  in  the  electrical  section,  and  many 
good  suggestions. 


T.  D.  LUKE. 


EMSWORTH  HOUSE, 
CLEVEDON, 

January,  1922. 


CONTENTS 


SECTIONS 
THERMOTHERAPY 

CHAPTER  PAGE 

I.    GENERAL    PRINCIPLES  -  -  1 

II.    HOT    AIR,     STEAM,     AND     TURKISH    BATHS,     TYRNAUER    AND 

BERTHE    APPARATUS  -         22 

III.    PHOTOTHERAPY,  ETC.  -  -  -  -  -          33 


SECTION  II 

HYDROTHERAPY 

I.    GENERAL    PRINCIPLES  •  49 

II.    ON    THE    TAKING    OF    BATHS  -  77 

III.  DOUCHES,    THE    WHIRLPOOL    BATH,    ETC.  -                                     -  99 

IV.  TECHNIQUE    OF   COMPRESSES,    PACKS,    AND  POULTICES            -  113 
V.     NAUHEIM,    PEAT,    MEDICATED    BATHS  -                  -                  -  133 


SECTION  III 
MASSOTHERAPY 

I.    MASSOTHERAPY  -       154 

II.    MANIPULATIVE    TREATMENT    AND    ZANDER   EXERCISES  -       173 

III.    MEDICAL    GYMNASTICS  -  -  -  -  -       195 


CONTENTS 


SECTION  IV 
THE  REST  CURE,  ETC. 

CHAPTER  PAGE 

I.    REST   CUKE,    SEA   VOYAGES  -  -  232 

II.    OPEN-AIR   SANATORIA   FOR   CONSUMPTION     -  -  245 

III.    CLIMATO -THERAPY    ......  255 


SECTION    V 

ELECTRO-THERAPEUTICS 

I.    GALVANISM    AND    FARADISM  -  267 

II.    THE    DYNAMO,    ETC.  -  317 

III.  X   RAYS    AND    THEIR   PRODUCTION     -                  -  -  348 

IV.  HIGH-FREQUENCY    AND    SINUSOIDAL    TREATMENT       -  -  363 

SECTION  VI 

DIETOTHERAPY 

I.    GENERAL   PRINCIPLES   AND    COMPOSITION    OF   FOOD  -  408 

II.    DIET    IN    HEALTH    AND    THE    INDIVIDUAL       -                  -  -  424 

III.  DIET     IN     DISEASE:     GASTRIC     DISEASE,     ANEURISM,  GOUT, 

RHEUMATISM,    ETC.  -  431 

IV.  VARIOUS    CURES:    BANTING    SYSTEM                    -                  -  -  449 
V.    DIET    IN    DIABETES;    ALLEN    CURE     ....  463 

INDEX                                   ......  468 


LIST  OF  ILLUSTRATIONS 


1.  Dowsing  Rays,  etc. 

2.  Chart  of  Thermometric  Equivalents 

3.  Dowsing  Apparatus  17 

4.  Dowsing  Radiator  (Local) 

5.  Local  Radiant  Heat  Bath  19 

6.  Greville  Generator 

7.  Hot-air  Cabinet      -  22 

8.  Steam  Cabinet        -  24 

9.  The  Calidarium  (Turkish  Bath)  26 

10.  The  Cooling  Room  27 

11.  The  Sun  Bath 

12.  Arenarium,  etc.       -  36 

13.  Indoor  Sun  Bath    -  37 

14.  Recumbent  Electric  Light  Bath    -  40 

15.  Electric  Light  Bath  41 

16.  Local  Light  Bath  -  42 
16 A.  Local  Light  Bath  43 

17.  Leucodescent  Lamp  -       48 

18.  Effect  of  Cold  Application  on  the  Pulse    -  -       58 

19.  Effect  of  Hot  Application  on  the  Pulse     -  -       58 

20.  Anterior  Cutaneous  Areas  reflexly  associated  with   In- 

ternal Parts        -  -       63 

21.  Posterior  Cutaneous   Area   reflexly   associated   with   In- 

ternal Parts        -  -       64 

22.  Cutaneous  Areas  associated  reflexly  with  Visceral  Pain 

(Dana)    -  65 

23.  Plombieres  Douche  70 

24.  Adjustable  Gravity  Syringe  -       71 

25.  Rectal  Irrigator     -  73 

26.  Winternitz's  Urethal  Psychrophore  73 

27.  An  improved  Foot  Bath    -  79 

28.  The  Arm  Bath        -  81 

29.  The  Leg  Bath  81 

30.  The  Foot  Bath       -  81 

31.  An  improved  Leg  Bath  84 

32.  Sitz  Bath,  with  Friction    -  85 

xi 


xii  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

33.  Ascending  Douche  Fitting  87 

34.  General  Bath,  and  Douche  Eoom  89 

35.  Sitz  Bath  Nauheim  Bath,  and  Packing  Couch  89 

36.  The  Half  Bath  with  Affusion  90 

37.  The  Half  Bath  with  Friction  90 

38.  The  Sitz  Bath  91 

39.  Back  Laving  or  Sponging  -  -       91 

40.  Modern  Type  of  Set-in  Bath  -  93 

41.  Pulse  Tracing:  (a)  Before,  (b)  After  a  full  Bath  95 

42.  The  Drip  Sheet      -  96 

43.  The  Drip  Sheet:  Further  Stage      -  97 

44.  Patient  Completely  Enveloped  97 

45.  Horizontal  Douche  100 

46.  Kellogg's  Nozzle     -  101 

47.  The  "  Rose  ''  for  Rain  or  Spray  Douche  101 

48.  Pulse  Tracing:  (a)  Before,  (b)  After  a  Spray  Douche  102 

49.  The  Aix  Douche  with  Two  Attendants      -  103 

50.  Pulse  Tracing:  («)  Before,  (b)  After  a  Vichy  Douche  1C4 

51.  The  Vichy  Douche  with  Three  Sprays  105 

52.  The  Broken  Horizontal  Jet  Douche  106 

53.  The  Aix  Douche     -  107 

54.  The  Horizontal  Percussion  Douche  108 

55.  The  Whirlpool  Bath  110 

56.  The  Whirlpool  Bath  111 

57.  Head  Compress       -  116 

58.  Throat  Compress   -  117 

59.  The  Kellogg  Compress       -  117 

60.  Compress  for  Tonsils  and  Pharynx  117 

61.  Chest  Compress      -  118 

62.  Compress  for  Trunk  119 

63.  Joint  Compress      -  120 

64.  Electro-thermal  Comprefs  121 

65.  The  Compresses  Applied    -  121 

66.  Application  of  Wet  Pack  -  123 

67.  The  Wet  Pack  Complete    -  124 

68.  The  Dry  Pack  1 24 

69.  Electric  Sweating  Mattress  125 

70.  Ice  Bag  131 

71.  Chapman's  Spinal  Ice  Bag  131 

72.  Diagram  of  Cardiac  Dulness  as  affected  by  Nauheim  Baths     136 

73.  Pulse  Tracing:  (ft)  Before,  (b)  After  a  Four- Week  Course 

of  Xauheim  Baths  -     137 

74.  The  Fischer  Kiefer  C02  Generator  for  Nauheim  Bath        -     141 

75.  Application  of  the  Fango  -  150 

76.  "Packed  Up"  150 

77.  Peat  Bath  -  152 

78.  Effieurage  carried  out  with  the  Finger  Tips  157 


LIST  OF  ILLUSTRATIONS  xiii 

FIG.  PAGE 

79.  Petrissage  with  a  single  Finger  or  Thumb  to  remove  In- 

flammatory Exudates     -             -  158 

80.  Petrissage  of  the  Forearm  with  both  Thumbs        -  -     158 

81.  Tapotement  with  the  Dorsal  Surface  of  the  Hand  -     159 

82.  "  Hacking  " — a  Variety  of  Tapotement    -  -     160 

83.  Petrissage  of  the  Arm  Muscles  with  Vibratory  Movement     160 

84.  Effleurage  performed  with  the  Entire  Palm  of  the  Hand 

rapidly  moving  towards  the  Knee  -     160 

85.  Eotation  of  the  Forearm  Muscles  -  -     162 

86.  Massage  of  the  Stomach     -  -     164 

87.  Massage  of  the  Abdomen  -  -     165 

88.  Massage  of  the  Abdomen  following  the  course  of  the  Colon     166 

89.  Vibrator  Applicators  -     171 

90.  Circumduction  of  the  Arm  -     177 

91.  Eotation  of  the  Arm  177 

92.  Mechano-Therapeutic  Apparatus  -     178 

93.  Mechano-Therapeutic  Apparatus  -     179 

94.  Mechano-Therapeutic  Apparatus  -     180 

95.  Mechano-Therapeutic  Apparatus  -     181 

96.  Mechano-Therapeutic  Apparatus  -     182 

97.  Mechano-Therapeutic  Apparatus  -     183 

98.  Mechano-Therapeutic  Apparatus  -     184 

99.  Mechano-Therapeutic  Apparatus  -     184 

100.  Mechano-Therapeutic  Apparatus  -     185 

101.  Mechano-Therapeutic  Apparatus  -     186 

102.  Mechanotherapy  Section    -  -     187 

103.  The  Bruce  Sutherland  System:  Chest  Exercise    -  -     201 

104.  Upper  Trunk  and  Lung  Exercise  -     202 

105.  Side,  Shoulder,  and  Back  Exercise  -     203 

106.  Striking-out  Movement      -             -  -     204 

107.  Windmill  Movement  -     205 

108.  Deep  Breathing  and  Chest-Expanding  Exercise    -  -     206 

109.  Exercise  for  the  Foot  and  Leg  Muscles      -  -     207 

110.  Leg-raising  Movement        -  -     208 

111.  Side-bending  Exercise        -  -     209 

112.  Chest,  Back,  and  Triceps  Exercise  -     210 

113.  Side-bending  Exercise        -             -  -     211 

114.  Chest,  Shoulder,  Back,  and  Arm  Exercise  -     212 

115.  Body-bending  Exercise      -  -     213 

116.  Rear-kicking  Movement    -  -     214 

117.  Trunk-swinging  Movement  -     215 

118.  Forward-bending  Exercise  -     216 

119.  Knee-bending  Exercise      -  -     217 

120.  Side-bending  Exercise        -  -     218 

121.  Neck  Exercise        -  -     219 

122.  Side-swinging  Exercise       -                                         -  -     220 

123.  Chest  Exercise        -             -              -              -             -  -     221 


xiv  LIST  OF  ILLUSTRATIONS 

*•!«.  PAGE 

124.  Side-bending  Exercise        -  -  222 

125.  Front-bending  Exercise     -  -  223 

126.  The  "  One,  Two,  Three  "  Movement  -  224 

127.  Double  Windmill  Movement  -  225 

128.  Side-bending  Exercise        -  -  226 

129.  Trunk-rolling  Movement    -  -  227 

130.  Stepping-out  Exercise        -  -  228 

131.  Upper  Arm  Exercise  -  229 

132.  Shoulder  and  Chest  Exercise  230 

133.  Dry  Cells    -  -  271 

134.  Nurse's  or  Patient's  Battery  -  277 

135.  Crank  rightly  placed  278 

136.  Crank  wrongly  placed   -     -  -  278 

137.  Double  Crank  Collector  279 

138.  Combined  Battery  with  Single  Collector   -  280 

139.  Button   and    Boiler   Electrodes;    and   Make   and   Break 

Handle   -  -  281 

140.  Indifferent  Electrodes        -  -  282 

141.  Chain  Mail  Electrodes        -  282 

142.  Wristlet  Electrode  for  Electric  Massage    -  283 

143.  Neat  Type  of  Combined  Battery  with  Double  Collector   -  284 

144.  Diagrammatic  Kepresentation  of  Induction  Coil  -  -  289 

145.  Diagram  of  Neef's  Hammer  and  Interrupter  -  290 

146.  Diagram  Illustrative  of  Induced  Currents  -  292 

147.  Scheme  of  Galvano-Fadratic  Battery  with  Sledge  Coil, 

Double    Collector,    Current    Reverser,    Galvanometer, 

and  Cell  Connections  shown       -  -  294 

148.  Diagram  illustrating  the   Regulation   of    the   Secondary 

Current  -  -  297 

149.  Du  BoLs  Raymond's   Coil,  with  Adjustable  Interrupter 

and  Sliding  Cone  for  regulating  Current  Strength          -  298 

150.  Apparatus  for  Faradization  -  299 

151.  Motor    Points    of   the    Radial    Nerve    and    the    Muscles 

supplied  by  it:  Dorsal  Surface  304 

152.  Motor  Points  of  Face  305 

153.  Motor  Points  of -the  Median  and  Ulnar  Nerves     -  -  305 

154.  Motor  Points  of- the  Sciatic  Nerve  and  its  Branches:  the 

Peroneal  and  Tibial  Nerves        -  306 

155.  Motor  Points  of  Thigh  307 

156.  Motor  Points  of  Leg  307 

157.  Electric  Massage  312 

158.  Lewis  Jones  Condenser  Testing  Set  -  314 

159.  Hernaman  Johnson  modified  Condenser  Apparatiis  -  315 

160.  Scheme   of   Electric  Bath  Circuit    to    show  how   Short- 

Circuiting  may  take  place  by  Means  of  the  Earth  Contact 

with  the  Waste  Pipe       -  -  323 

161.  Waste  Pipe  with  Open  Gully  -    -  •  -  323 


LIST  OF  ILLUSTRATIONS  xv 

FIG.  PAGE 

162.  The  Switchboard                 -  .     324 

163.  Diagram  of  Switchboard  with  Lamp  and  Wire  Resistance    326 

164.  The  Rheostat  (Fine  Wire)  -     326 

165.  De  Watteville  Commutator  -     329 

166.  Current  Reverser    -  -     329 

167.  Galvanoset,  with  Faradic  Coil  attached  -     331 

168.  The  Faradiset  332 

169.  Scheme  of  Circuit  in  Galvanoset    -  -     332 

170.  Galvanoset  in  Action  -     333 

171.  Four- Way  Connectors        -  335 

172.  The  Multostat  (Pantostat  Form)  -  336 

173.  Curve  of  a  Sinusoidal  Current        -  -     338 

174.  Curve  of  Secondary  Current  of  a  Faradic  Coil       -  -     338 

175.  Diagram    showing    arrangement    for    producing    Three- 

Phase  Currents  -  -     339 

176.  Diagram    showing    arrangement    for    producing   Three- 

Phase  Currents  -  -     339 

177.  Diagram    showing    arrangement    f.or    producing   Three- 

Phase  Currents  -  339 

178.  Triphase  Switchboard  with  Motor  341 

179.  Polyhpase  Switchboard  and  Motor  342 

180.  Special  Commutator  for  a  Four-Cell  Schnee  Bath  344 

181.  The  Schnee  Four-Cell  Bath  345 

182.  Diagrammatic      Representations      ot      Applications  of 

Current  in  Schnee  Bath  346 

183.  Diagrammatic  Scheme  of  X-Ray  Apparatus  351 

184.  Complete  X-Ray  Apparatus  352 

185.  Ruhmkorff     Induction     Coil,     fhown    Diagrammatically 

(Williams)  -     354 

186.  Chart  of  an  X-Ray  Tube  -  357 

187.  Modern  Type  of  X-Ray  Tube  358, 

188.  Oudin's  Resonator  and  Oil  Condenser       -  364 

189.  The  Autonome  or  Gas-Mercury  Interrupter  (Gaiffe)  366 

190.  Stand  with  Oil  Condenser  and  Milliamperemeter  369 

191.  Multiple  Silent  Spark  Gap  370 

192.  The  d'Arsonval- Gaiffe  Installation  for  High-Frequency, 

Static  Electricity,  and  X  Rays-  371 

193.  Hedgehog  Pattern  Effleuve  Brush    for    applying  High- 

Frequency  Current  Discharges  -  372 

194.  Professor  Doumer's  Rectal  Electrode   for  Treatment  of 

Haemorrhoids,  etc.  -     372 

195.  Grand  Model  Grip  Handle  for  Patient  -     372 

196.  Hot- Wire  Milliamperemeter  -     373 

197.  Bisserie's  Handle   -  373 

198.  H.  F.  and  Diathermy  Tracings  377 

199.  Limpet  Electrodes  378 

200.  Limpet  Electrodes               -             -              -  -     379 


XVI 

FIO.  PAGE 

201.  Diathermy  Apparatus        -  -     381 

202.  Diathermy  Electrodes        -  -     382 

203.  Static  Machine       -  -     385 

204.  Handle  with  Copper  Electrode  -  394 

205.  Copper  and  Zinc  Electrodes  -     394 

206.  Interrupter  for  Bergoni6  Chair  -  -     398 

207.  Oscillogram  (Bergoni6)      -  -     399 

208.  Oscillogram  (Bergonie")      -  399 

209.  Bergoni6  Switchboard       -  401 

210.  Bei-gome"  Chair       ......     402 


MANUAL  OF 

PHYSIO-THERAPEUTICS 


CHAPTER  I 
GENERAL  PRINCIPLES 

THE  use  of  heat,  in  one  form  or  other,  in  therapeutics  dates 
back  to  the  dim  and  distant  ages  of  remotest  antiquity; 
even  animals,  when  ill,  instinctively  have  recourse  to  the 
radiant  heat  of  the  sun.  Doubtless  the  first  idea  of  the  use 
of  heat  as  a  curative  agent  arose  from  the  beneficial  effects 
experienced  from  submitting  the  body  to  the  influence  of 
the  solar  rays. 

The  therapeutical  applications  of  heat  are  innumerable, 
and,  with  the  progress  of  science,  have  gradually  extended 
their  range  from  the  linseed  poultice  of  former  times  to  the 
modern  and  elegant  appliances  for  treatment  by  means  of 
moist  or  dry  heat;  from  the  old  Roman  sweating-houses  to 
the  luxurious  and  well-appointed  Turkish  baths  of  the 
present  day. 

Although  originally  practised  by  enthusiasts  on  more 
or  less  empiric  lines— in  common  with  many  other  forms 
of  treatment  which  have  subsequently  received  the  warm 
approval  of  medical  men  and  scientists — -the  use  of  heat  in 
its  various  forms  has  during  the  last  century  been  the  subject 
of  study  by  numerous  medical  men  throughout  the  world. 

In  1840,  Guyot  issued  his  "  Trait  e  de  ITncubation,"' 
the  first  serious  study  on  hot  air  and  the  employment  of 
high  temperatures  for  the  alleviation  of  pain,  especially 
with  reference  to  affections  of  the  bones. 

1 


2  MANUAL  OF  PHYSIO-THERAPEUTICS 

In  1844,  Chautard,  perceiving  the  value  attaching  to 
luminous  radiant  heat,  strongly  recommended  its  adoption 
in  treating  rheumatism. 

Heat  may  be  employed  in  three  different  forms:  1.  Moist 
heat.  2.  Dry  heat.  3.  Luminous  radiant  heat. 

1.  Moist  Heat.— Without    going    into    the     question    of 
ordinary  baths,  poultices,  fomentations,  etc.,   we  will  now 
consider  what  takes  place  in  vapour  baths,  of  which  the 
temperature  varies  from  24°  C.  to  49°  C.     The  enclosure 
within   which   such  baths  are   gi^en   consists   of   a   closed 
chamber  into  which  is  allowed  to  flow  either  pure  water 
vapour  or  vapour  charged  with  medicinal  substances.     The 
patient  usually  bears  without  inconvenience  a  temperature 
of  from.  24°  C.  to  44°  C.,  but  beyond  this  latter  temperature 
and  up  to,  say,  50°  C.,  the  respiration  and  circulation  are 
very  noticeably  accelerated,  and  such  untoward  events  as 
vertigo,  loss  of  consciousness,  congestion,  haemorrhage,  etc., 
are  to  be  feared.     These  are  due  to  the  hot  vapour,  which 
renders  respiration  laborious  and  painful,  and  also  to  the 
obstruction    offered    to    the    evaporation    of    the    moisture 
given  off  from  the  body  in  an  atmosphere  already  super- 
saturated with  moisture.     In  order  to  get  rid  of  the  first  of 
these  difficulties,  there  has  been  introduced  the  box  bath, 
which  consists  of  an  enclosure  within  which  only  the  body  is 
enveloped  in  vapour,  the  head  being  outside  the  box,  thus 
permitting  the  lungs  to  receive  air  from  without.       In  spite 
of  this,  when  one  enters  a  room  in  which  such  box  baths 
are   being  given,   the   high  temperature   is  generally   very 
noticeable,  as  are  also  the  humidity  and  disagreeable  odour 
of  the  atmosphere  which  one  breathes.     It  is  practically 
impossible  to  remedy  the  difficulty  of  evaporation  of  the 
perspiration. 

2.  Dry  Heat. — Among    the    applications   of   dry   heat   in 
which  air  does  not  play  the  part  of  the  conducting  medium, 
and  in  which  the  temperature  does  not  get  beyond  49°  C. 
to  55°  C.,  are  bran,  salt,  or  hot  sand  compresses,  dry  fomen- 
tations, etc. 

The  hot-air  bath  represents  the  more  general  application 
of  dry  heat;  the  temperature  varies  from  40°  C.  to  74°  C., 
and  may  even  reach  .112°  C.,  the  maximum  temperature 


GENERAL  PRINCIPLES  3 

bearable  for  any  length  of  time;  but  it  is  not  prudent  to 
submit  patients  to  this  latter  temperature. 

In  1893  Tallerman  demonstrated  the  possibility  of  attain- 
ing with  dry  heat  temperatures  unknown  until  then.  His 
apparatus  consists  of  a  metal  cylinder  heated  by  numerous 
gas  jets.  The  cylinder  is  closed  at  one  end,  with  the  excep- 
tion of  one  small  opening  where  a  ventilator  is  fixed.  At 
the  other  end  is  fixed  a  movable  screen  of  special  cloth,  with 
an  opening  in  the  centre  through  which  the  affected  limb 
is  passed.  The  apparatus  thus  consists  of  a  closed  space 
with  a  means  of  securing  ventilation.  Considerable  ex- 
perience in  English  and  American  hospitals  demonstrates 
that  a  temperature  of  148°  C.  can  be  borne  without  incon- 
venience, and  gives  good  therapeutic  results  in  some  cases. 
The  apparatus  was  to  all  intents  and  purposes  a  gas  oven, 
and  products  of  combustion  are  distinctly  perceptible. 

3.  Luminous  Radiant  Heat. — This  is  either  natural  or 
artificial:  natural  in  sun  baths;  artificial  in  the  Dowsing 
baths.  The  latter  system  of  baths  possesses  many  and 
considerable  advantages  over  all  other  systems,  and  permits 
of  a  temperature  of  upwards  of  260°  C.  being  attained,  and 
maintained  with  safety. 

In  order  to  fully  appreciate  the  medical  value  of  luminous 
radiant  heat,  it  is  necessary  to  explain  here  certain  of  its 
physical  properties  which  are  but  little  understood  at  the 
present  day. 

Some  Physical  Facts  in  regard  to  Luminous 
Radiant  Heat. 

Luminous  radiant  heat — of  which  the  sun  represents  the 
best  possible  example — is  the  conjunction  of  radiant  heat 
with  light  and  certain  chemical  rays.  All  combustion  with 
flame  creates  luminous  radiant  heat,  but  it  is  not  always 
necessary  to  use  combustion,  in  the  chemical  sense  of  the 
word,  to  obtain  this  mode  of  transformation  of  energy. 
Electricity  can  transform  itself  directly,  in  vacuo,  into 
luminous  radiant  heat.  This  is  the  case  with  the  Dowsing 
lamp,  which  emits  simultaneously  heat  rays  and  light  rays 
(see  Fig.  1). 


4  MANUAL  OF  PHYSIO-THERAPEUTICS 

Radiant  heat,  light  rays,  and  chemical  rays  are  three 
types  of  radiant  energy;  from  the  physical  point  of  view 
there  is  no  essential  difference  between  them,  and  their  laws 
of  propagation  are  identical. 

Radiant  heat  is  that  which,  emanating  from  a  heated  body, 
passes  through  other  bodies,  described  as  diathermanous,  as 
light  passes  through  diaphanous  bodies. 

A  part  of  the  sun's  heat  travels  through  the  atmosphere 
as  light,  without  being  absorbed  in  it;  the  fire  from  the 


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DOWSING  RAYS 

FIG.  l. 


FINSEN   RAYS 


hearth  warms  us  at  a  distance  without  the  heat  which  it 
emits  being  absorbed  by  the  air  which  separates  it  from  us. 
This  is  what  is  known  as  radiation. 

Radiation  consists  in  the  vibrations  of  ether  produced  by 
the  impulse  of  molecular  movements  of  a  radiant  body. 
Luminous  rays  are  perceptible  to  us  by  the  eyes,  and  heat 
rays  by  the  skin  and  flesh :  but  the  invisible  rays  of  heat, 
the  luminous  rays  of  light,  and  the  chemical  rays  are  each 
represented  by  ether  vibrations,  only  distinguishable  by 
difference  in  length  of  wave.  Tyndall  demonstrated  this 
in  his  studies  on  the  spectrum;  in  fact,  when  we  observe 
the  obscure  region  of  the  spectrum,  we  see  that  the  heat 
rays  become  more  and  more  intense  in  proportion  to  the 


GENERAL  PRINCIPLES  5 

proximity  of  the  luminous  rays;  at  the  same  time  the  heat 
waves  acquire  a  greater  amplitude,  causing  greater  energy 
of  vibration,  the  energy  of  vibration  being  proportional  to 
the  square  of  the  amplitude.  Thus,  to  obtain  high  tempera- 
tures, a  source  of  luminous  heat  is  preferable  to  all  others. 

In  spite  of  the  identity  in  origin  of  obscure  and  luminous 
heat,  it  is  not  less  true  that  luminous  heat  possesses  pro- 
perties peculiar  to  itself. 

Practically,  the  transmission  of  obscure  heat  is  effected 
by  convection,  and  consequently  indicates  the  raising  of 
the  temperature  of  the  surrounding  atmosphere;  for 
example,  to  raise  by,  for  instance,  30°  the  temperature 
of  a  body  separated  some  distance  from  a  source  of  obscure 
heat,  it  is  absolutely  necessary  that  the  atmosphere  of  the 
intervening  space  be  also  raised  by  30°. 

Luminous  radiant  heat  will  effect  its  purpose  without 
raising  the  temperature  of  the  surrounding  atmosphere; 
its  rays,  like  the  rays  of  the  sun,  do  not  by  convection  carry 
the  heat  from  point  to  point,  but  merely  energy  in  the 
shape  of  vibrations,  which  energy  is  transformed,  or  con- 
verted, into  effective  heat  in  encountering  obstructing 
bodies. 

Luminous  radiant  heat  may  be  diffused  as  light,  and 
reflected  and  directed  by  means  of  suitably  arranged  re- 
flectors. This  may  be  readily  demonstrated  by  arranging 
opposite  each  other,  some  little  distance  apart,  twTo  large 
spherical  or  parabolic  mirrors  of  burnished  copper  in  such  a 
manner  that  their  axes  are  coincident,  and  placing  a  piece 
of  live  coal  or  other  lighted  substance  in  front  of  the  one, 
and  a  piece  of  tinder  in  front  of  the  other,  when  it  will  be 
found  that  the  tinder  almost  immediately  bursts  into  flame. 

Luminous  rays  and  chemical  rays  play  an  important 
part  in  radiant  heat,  and  it  may  be  useful  at  this  point  to 
mention  some  features  of  special  interest.  Lender  certain 
conditions,  light  becomes  converted  into  heat.  A  striking 
example  of  this  is  shown  in  connection  with  a  conservatory. 
If,  when  the  sun  is  shining  brightly,  all  ventilation  is  stopped 
for  a  few  hours,  the  heat  within  the  conservatory  becomes 
intolerable.  The  heat  rays  alone  are  not  responsible  for 
this  increase  in  temperature,  for,  as  is  well  known,  heat  rays 


6  MANUAL  OF  PHYSIO-THERAPEUTICS 

only  penetrate  through  glass  to  the  extent  of  33  per  cent., 
a  percentage  quite  insufficient  to  account  for  the  rapid  rise 
in  temperature  within  the  conservatory.  The  explanation 
is  to  be  found  in  the  fact  that  the  luminous  rays,  which  pass 
through  glass  practically  without  diminution,  coming  into 
contact  with  the  plants  and  other  objects  within  the  con- 
servatory, are  absorbed  in  such  subjects,  and  thus  converted 
into  effective  heat.  Tyndall  has  demonstrated  the  same 
thing  by  the  following  ingenious  experiment.  He  passed 
a  beam  of  electric  light  through  water  to  absorb  the  heat 
rays,  and  then,  by  passing  the  resultant  rays  through  a 
lens  of  ice,  he  set  fire  to  some  black  paper  and  ignited  gun- 
cotton  on  the  other  side,  showing  that  it  was  not  the  heat 
rays  which  brought  about  that  result,  but  the  light  rays. 
In  other  words,  the  wave  lengths  were  altered,  they  were 
lowered  in  refrangibility,  and  converted  into  heat. 

Certain  substances,  amongst  others  platinocyanide  of 
barium,  have  the  property  of  absorbing  rays  of  a  certain 
wave  length  and  of  emitting  rays,  more  or  less  luminous, 
of  a  different  wave  length.  This  interesting  phenomenon 
constitutes  fluorescences,  of  which  the  radioscope  represents 
the  most  important  application. 

Thus  we  see  that  luminous  radiant  heat  is  formed  by 
the  blending  together  of  heat  rays,  luminous  rays,  and 
chemical  rays;  but  it  is  possible  to  eliminate  either  one 
or  other,  and  to  have  separately  either  heat  rays,  light 
rays,  or  chemical  rays. 

In  order  to  separate  heat  rays  from  luminous  rays,  we 
utilize  the  fundamental  difference  between  their  action 
on  the  bodies  they  meet.  Amongst  such  bodies,  some 
completely  stop  the  passage  of  radiant  heat,  and  for  this 
reason  are  called  athermanous;  others,  which  permit 
the  passage  of  radiant  heat,  are  called  diathermanous. 
Diathermanous  bodies  are  not  necessarily  transparent,  nor 
are  athermanous  ones  necessarily  opaque.  An  alum  solution 
allows  the  light  to  pass  through,  but  completely  stops  the 
passage  of  heat.  Iodine,  on  the  other  hand,  in  solution  of 
bisulphide  of  carbon,  allows  the  invisible  heat  rays  to 
pass,  but  effectively  obstructs  the  light  rays.  These  facts 
are  easily  demonstrated.  Water  will  boil  by  light  which 


GENERAL  PRINCIPLES  1 

has  passed  through  iodine  and  is  concentrated  in  a  glass 
tube  containing  water.     If  the  iodine  is  replaced  by  an 
alum  solution,  the  boiling  ceases  instantly. 
Summarizing  briefly,  it  may  be  stated  that : 

1.  Luminous  radiant  heat  is  made  up  of  different  radia- 

tions  or  vibrations,    which   can  be  separated   one 
from  the  other. 

2.  It  can  be  directed  on  to  a  body  without  raising  the 

temperature  of  the  surrounding  atmosphere. 

3.  It  can  penetrate  glass  without  diminution  of  potency. 

4.  It  can  be  reflected  by  means  of  reflectors. 

5.  It  can  be  so  diffused  by  means  of  special  appliances 

that  very  high  temperatures  may  be  attained  by  the 
air  enclosed  in  a  given  space. 

The  Physiological  Action  of  luminous  radiant  heat, 
which  is  composed  of  heat,  light,  and  chemical  rays,  each 
possessing  specific  and  important  properties,  is  determined 
by  the  combined  action  of  all  such  rays  upon  the  body. 
This,  from  the  therapeutic  point  of  view,  is  of  much  interest, 
as  it  is  such  a  combination  of  rays  which  in  practice  is  most 
often  brought  into  requisition. 

One  remarkable  feature  at  once  attracts  attention.  The 
human  body  can  bear,  with  luminous  radiant  heat,  much 
higher  temperatures  than  have  hitherto  proved  possible 
by  any  other  application  of  heat.  The  complete  or  whole 
body  bath  can  be  used  without  danger  at  a  temperature 
of  upwards  of  200°  0.;  this  bath  is  usually  given  with  a 
temperature  ranging  approximately  from  149°  to  205°  C., 
while  with  the  local  bath  a  temperature  of  upwards  of 
260°  C.  may  be  attained. 

At  first  sight  it  would  naturally  be  thought  that  such 
high  temperatures  must  necessarily  be  productive  of  con- 
siderable risk  to  the  human  organism.  In  hot-air  (Turkish) 
baths  the  temperature  rarely  rises  beyond  79°  C.  Cutaneous 
perspiration  and  respiration  are  the  only  means  at  the 
disposal  of  the  body  for  maintaining  its  temperature  under 
such  conditions.  This  remains  equally  true  when  using 
the  Dowsing  system,  with  this  very  important  difference, 
that  the  action  of  the  skin  and  lungs  can  be  raised  to  the 


8  MANUAL  OF  PHYSIO-THERAPEUTICS 

highest  possible  pitch,  because  the  respiration  of  the  patient 
is  not  affected,  the  air  inhaled  being  of  the  normal  tempera- 
ture. Cutaneous  perspiration  is  an  example  of  the  well- 
known  fact  that  water  cannot  be  converted  into  vapour 
without  absorbing  and  rendering  latent  a  considerable 
amount  of  heat.  The  quantity  of  water,  in  the  form  of 
vapour,  exhaled  by  the  human  body  has  been  estimated  at 
32  ounces  per  diem.  The  heat  absorbed  and  rendered 
latent  by  such  evaporation  is,  according  to  the  most  careful 
calculations,  equal  to  that  which  would  raise  the  same 
weight  of  water  from  0°  to  625°  C. 

Cutaneous  perspiration  can  thus  be  considered  a  most 
powerful  agent  in  regulating  the  temperature  of  the  human 
body,  and  observation  demonstrates  that  it  becomes  more 
active,  and  therefore  absorbs  more  heat,  as  the  temperature 
around  it  is  raised.  But  in  order  to  attain  this  result  it  is 
essential  that  the  air  in  contact  with  the  skin  be  kept  free 
from  moisture,  the  presence  of  which  tends  to  the  reduction 
of  the  perspiration,  and  in  fact  stops  it  entirely  when  the 
atmosphere  becomes  supersaturated.  To  ensure  the  requi- 
site dryness  of  air,  it  is  therefore  essential  that  some  more 
or  less  perfect  system  of  ventilation  should  be  obtained. 
It  is  for  this  reason  that  the  ordinary  hot-air  bath,  having 
no  appreciable  ventilation,  may  become  a  source  of  no 
little  danger  to  the  patient. 

The  evaporation  which  takes  place  in  the  pulmonary 
cavities  constitutes  a  further  means  which  the  body  possesses 
for  maintaining  its  proper  temperature  in  a  superheated 
atmosphere.  Its  intensity  is  in  inverse  ratio  to  the  moist 
condition  of  the  air. 

To  undergo  high  temperatures,  it  is  essential  that  the 
temperature  of  the  body  should  remain  normal.  To 
accomplish  this,  the  heat  which  is  given  off  must  be  almost 
entirely  converted  into  another  form  of  energy — viz.,  the 
latent  heat  of  vapour. 

The  Dowsing  appliances,  utilizing  luminous  radiant 
heat  by  direct  radiation  without  heating  the  surrounding 
atmosphere,  do  not  increase  the  temperature  of  a  room, 
and  in  no  way  affect  the  breathing  of  the  patient;  and 
by  diffusing  the  heat  in  a  confined  space  automatically 


ventilated  the  same  results  follow.  The  constant  renewal 
of  the  air  in  contact  with  the  body  of  the  patient,  securing 
freedom  from  saturation,  enables  temperatures  hitherto  un- 
known to  be  obtained  by  the  use  of  luminous  radiant  heat. 

Remarkable  potency  and  uniformity  are  characteristics  of 
the  physiological  action  of  these  high  temperatures,  which 
have  been  closely  studied  by,  amongst  others,  Hedley 
and  Douglas  Kerr,  of  Bath.  The  results  obtained  by 
them,  which  are  very  similar  to  those  given  by  Chretien, 
of  the  Salpetriere  Hospital,  may  briefly  be  stated  as  follows : 

Very  marked  redness  of  the  skin,  due  to  the  dilatation 
of  the  subcutaneous  bloodvessels;  more  or  less  profuse 
perspiration;  more  or  less  rapid  acceleration  of  the  pulse; 
speedy,  sometimes  immediate,  alleviation  of  pain;  tempo- 
rary increase  of  the  temperature  of  the  body;  increase  of 
the  solid  matter  of  the  urine,  particularly  of  the  urea  and  uric 
acid;  and  greater  elimination  of  carbonic  acid  by  the  lungs. 

The  redness  of  the  skin  is  not  uniform,  assuming  a  red- 
marbled  appearance,  caused  by  a  dilatation  of  the  blood- 
vessels forming  the  capillary  network  in  the  cellular  spaces 
of  the  corium.  The  cutaneous  perspiration  differs  in 
patients,  but  is  always  more  profuse  in  this  than  in  ordinary 
hot-air  baths.  The  perspiration  increases  with  the  heighten- 
ing of  the  temperature,  and  spreads  all  over  the  surface  of 
the  body,  even  in  local  applications,  when  the  area  under 
treatment  may  be  very  limited. 

The  acceleration  of  the  pulse,  although  variable,  is  less 
pronounced  than  is  the  case  in  hot-air  baths,  and  results 
from  the  dilatation  of  the  peripheral  bloodvessels,  which 
facilitate  the  action  of  the  heart  and  permit  of  more  complete 
and  stronger  contractions.  An  hour  after  a  luminous 
radiant-heat  bath  the  pulse  becomes  slower  but  stronger 
than  before,  especially  in  cases  of  patients  suffering  from 
weak  hearts. 

The  sedative  action  of  the  luminous  radiant  heat  treat- 
ment is  very  marked.  In  cases  of  acute  gout  its  action  is 
practically  immediate,  freedom  from  pain  being  experienced 
almost,  if  not  quite,  from  the  first  application  of  the  rays 
to  the  body;  in  cases  of  sprains,  contusions,  articular  or 
muscular  rheumatism,  and  neuralgia,  no  inconsiderable 


10 


MANUAL  OF  PHYSIO-THERAPEUTICS 


CENTIGRADE.  FAHRENHEIT. 

260 £00.... 


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300 


116  . 

100 
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72. 


240 


212 
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IS 

Under  12 


Radiant  Heat  Bath,  maximum  bearable  heat 
without  danger,  for  the  treatment  of  single 
limbs. 


Radiant  Heat  Bath,  maximum  bearable  heat  for 
full  body  bath. 


Radiant  Heat  Bath,  comfortable. 


Very  hot  Turkish  Bath. 

Water  boils. 

"  Calidarium  "—Turkish  Bath. 

"  Tepidarium  " — Turkish  Bath. 

Fango  Mud  Bath,  bearable. 
Vapour  Bath,  unbearable. 

Fango  Mud  Bath,  comfortable. 

Very  Hot   \ 

Hot 

Warm 

Tepid          \  WATKR 

Cool 

Cold 

Very  Cold 


APPLICATIONS. 

"---.    uooi 

..   Cold 

32  -L 

FIG.  2. — CHART  SHOWING  TIIERMOMETRIC  EQUIVALENTS. 


GENERAL  PRINCIPLES  11 

diminution  of  pain  is  experienced  from  the  first,  with  an 
increasing  feeling  of  relief  after  each  succeeding  application. 

In  a  Dowsing  bath  having  a  temperature  of  about  94°  C, 
and  a  duration  of  from  thirty  to  forty  minutes,  the  tempera- 
ture of  the  body,  taken  under  the  tongue,  shows  a  gradual 
increase  of  from  six-  to  eight- tenths  of  a  degree;  rarely 
more  than  a  degree.  Within  about  twenty  minutes  after  the 
bath  the  temperature  returns  to,  and  remains,  normal. 

In  a  Turkish  bath,  on  the  other  hand,  a  stay  of  only  ten 
minutes,  with  a  temperature  of  about  107°  C.,  is  sufficient 
to  raise  the  temperature  of  the  body,  taken  under  the 
tongue,  more  than  a  degree  (Dobson).  Twenty  to  thirty 
minutes  after  leaving  the  bath  the  temperature  has  not 
only  fallen  to  the  initial  point,  but  has  actually  gone  below 
it  (Hoppe). 

The  increase  in  elimination  of  the  solid  matters  in  the 
urine,  particularly  of  the  urea  and  uric  acid,  seems  to  be 
mainly  brought  about  by  the  increase  in  the  temperature 
of  the  body,  by  the  more  rapid  flow  of  the  blood  through 
the  expanded  bloodvessels,  and  by  the  profuse  perspiration 
which  is  induced.  A  remarkable  feature  is  that,  during 
a  course  of  the  Dowsing  baths,  it  is  generally  found  that 
there  is  a  greater  volume  of  urine  discharged  than  usual. 

There  is  always  a  very  considerable  elimination  of  carbonic 
acid  from  the  lungs,  resulting  in  a  general  stimulation  of 
the  digestive  organs.  There  is  sometimes  a  slight  accelera- 
tion in  respiration,  but  usually  it  remains  normal. 

The  combination  of  luminous  rays,  chemical  rays,  and 
heat  rays  gives  to  luminous  radiant  heat  properties  not 
possessed  by  obscure  heat.  Two  experiments  made  by 
Bain,  of  Harrogate,  show  very  important  results.  In  the 
first  experiment,  the  hind  leg  of  a  dog — anaesthetized  with 
ether — was  placed  in  a  non-luminous  hot-air  case.  In  the 
second  experiment,  with  the  leg  under  the  same  conditions, 
the  Dowsing  apparatus  was  used,  and  the  leg  exposed  to 
luminous  radiant  heat.  The  results  obtained  in  each  case 
were  as  follows : 

Obscure  or  Xon-     Luminous 
Luminous  Heat.         Heat. 

Temperature  of  the  air  in  case         .  .          .  .         150°  C.         120°  C. 
Elevation  of  the  temperature  of  the  body  .  .         0-5°  0-1° 

Elevation  of  the  temperature  of  the  limb     ..          1-8°  4-2° 


12          MANUAL  OF  PHYSIO-THERAPEUTICS 

From  the  physiological  point  of  view  it  is  not  possible 
to  form  conclusions  applicable  to  human  beings,  owing  to 
the  difference  in  the  cutaneous  functions,  but  it  is  never- 
theless clear  that  luminous  heat  at  120°  C.  brings  about 
a  rise  of  temperature,  both  local  and  general,  greater  than 
is  produced  by  non-luminous  heat  at  150°  C.,  showing  that 
luminous  radiant  heat  possesses  greater  penetrative  power 
than  non-luminous. 

Analysis  of  the  various  results  obtained  under  the  in- 
fluence of  luminous  radiant  heat  enables  us  clearly  to  trace 
its  curative  effect  in  various  diseases,  and  its  remarkably 
sedative  influence  in  the  alleviation  of  pain.  Hedley  has 
given  a  very  good  explanation  of  this.  He  takes,  as  an 
example,  one  of  the  various  forms  of  rheumatic  or  gouty 
arthritis,  for  which  radiant  heat  baths  are  specially  recom- 
mended. Such  an  example,  however,  is  complicated  by 
conditions  peculiar  to  itself,  and  it  is  perhaps  simpler  to 
consider  the  case  of,  say,  a  recent  sprain,  which  will  illustrate 
much  more  clearly  what  takes  place. 

As  an  immediate  consequence  of  such  an  injury,  the 
distension  of  the  ligaments,  the  more  or  less  pronounced 
strain,  and  the  laceration  of  the  fibrous  tissue,  cause  an 
extravasation  of  blood  in  the  tissues,  and  often  in  the  joint 
itself.  A  more  or  less  extensive  swelling  rapidly  sets  in, 
followed  by  signs  of  local  inflammation.  The  pain  is  intense, 
and  on  the  slightest  movement  becomes  excruciating.  At 
the  same  time,  both  the  larger  and  smaller  bloodvessels 
become  dilated,  with,  consequently,  a  larger  flow  of  blood 
through  them  than  is  usual.  The  dilatation  of  the  capil- 
laries fed  by  the  smaller  bloodvessels  in  question  is  only  pro- 
portionately less  pronounced,  and  is  brought  about  primarily 
by  the  flow  of  blood  being  greater  than  they  can  normally 
contain.  The  normal  difference  of  pressure  between  the 
blood  of  the  capillaries  and  the  lymph  contained  in  the 
lymphatic  spaces  increases  considerably,  and  brings  about 
the  diffusion  of  a  certain  amount  of  lymph.  It  is  even 
possible  that  the  capillary  circulation  may  be  stopped  by 
congestion  brought  about  by  the  adhesion  of  red  and  white 
corpuscles;  in  this  case  the  increased  activity  of  the  circula- 
tion is  followed  by  stagnation,  but  the  outflow  of  the  cellular 


GENERAL  PRINCIPLES  13 

elements  being  very  active,  their  disintegration  will  rapidly 
produce  coagulation  of  the  lymph  surrounding  the  seat  of 
injury. 

The  surrounding  tissues,  which  are  comparatively  much 
less  hurt,  become  swollen,  because  the  lymphatics  are 
unable  to  absorb  the  products  of  the  vascular  exudations, 
and  are  distended  by  the  lymph,  which  does  not  coagulate, 
since  it  is  no  longer  in  contact  with  elements  in  course  of 
disintegration.  The  painful  symptoms  result  mostly  from 
the  pressure  produced  by  an  exudation  which  has  no  outlet 
in  a  joint  protected  by  ligaments  and  fibrous  tissue  which 
cannot  expand.  The  lymphatic  system,  by  extra  activity 
of  its  absorptive  functions,  endeavours  to  counteract  this 
abnormal  pressure,  but  the  compensation  is  not  sufficient, 
and  more  or  less  swelling  is  the  rule. 

What  is  the  action  of  luminous  radiant  heat  in  such 
cases  ?  Shortly  after  submitting  the  limb  to  the  influence 
of  luminous  radiant  heat  the  skin  becomes  red,  and  profuse 
perspiration  sets  in.  The  redness  of  the  skin  is  due  to  the 
dilatation  of  the  cutaneous  bloodvessels,  whilst  the  perspira- 
tion results  from: — (1)  The  dilatation  of  the  bloodvessels, 
particularly  of  those  capillaries  which  are  in  intimate  relation 
to  the  perspiring  and  sebaceous  glands  and  follicles;  (2)  the 
direct  stimulation  of  the  cellular  elements  and  glands  by 
the  various  radiations. 


Therapeutic  Indications. 

All  affections  which  are  benefited  by  hot-air  baths, 
whether  local  or  general,  are  very  successfully  treated 
by  luminous  radiant  heat.  Owing  to  the  perfection  in 
ventilation  attained  by  the  Dowsing  apparatus,  it  is  possible, 
without  risk,  to  submit  patients  to  temperatures  varying 
from  150°  to  232°  C.  in  the  complete — or  whole-body — bath, 
while  with  the  appliance  for  local  baths  a  temperature  of 
upwards  of  260°  C.  may  safely  be  given. 

The  physiological  action,  proved  by  numerous  actual 
tests,  enables  the  results  which  may  be  anticipated  in  the 
treatment  of  various  affections  to  be  set  out  with  a  very 
considerable  degree  of  certainty.  They  are  as  under : 


14          MANUAL  OF  PHYSIO-THERAPEUTICS 

Gout. — A  single  bath  is  often  sufficient  to  cause  a  very 
considerable  alleviation  of  pain  in  cases  of  acute  gout.  The 
sedative  effect  usually  begins  to  be  felt  at  a  temperature 
of  about  171°  C.,  and  continues  for  several  hours  after  the 
bath,  which  usually  lasts  for  from  thirty  to  forty-five 
minutes.  When  the  pain  returns,  it  is  always  less  severe. 
Douglas  Kerr  usually  prescribed  a  Dowsing  complete  bath 
in  the  morning,  and  a  local  application  at  mid-day.  The 
duration  of  the  severest  attacks  is  then  reduced  to  a 
few  days. 

Immediately  after  the  commencement  of  the  treatment 
it  is  noticeable  that  the  urine  becomes  more  abundant 
and  richer  in  urea,  urates,  and  uric  acid. 

In  cases  of  subacute  or  chronic  gout,  not  only  is  there 
alleviation  of  pain,  but  often  the  deformities  of  the  joints, 
so  characteristic  of  this  affection,  become  less  pronounced, 
and  even  disappear  entirely,  while  the  improvement  in 
the  functions  of  elimination  has  a  rapid  and  favourable 
influence  on  the  general  health  of  the  patient. 

Rheumatism. — In  a  case  of  polyarthritic  febrile  rheuma- 
tism, where  salicylates  and  antipyrin  did  not  seem  to  give 
very  appreciable  results,  a  Dowsing  bath  of  150°  C.,  lasting 
on  an  average  about  twenty  minutes,  was  given  daily. 
There  was  an  almost  immediate  alleviation  of  pain,  the 
swelling  decreased,  the  temperature  was  lowered,  and  the 
volume  of  urine  augmented.  The  illness  lasted  for  a  period 
of  twelve  days,  but  the  pain  was  very  considerably  dimin- 
ished from  the  time  of  the  first  application  of  the  luminous 
radiant  heat,  and  convalescence  resulted  without  any  com- 
plications. It  is,  of  course,  not  possible  to  draw  conclusions 
from  any  single  observation,  but  the  results  in  this  case 
were  such  as  to  justify  recourse  to  similar  treatment  under 
like  conditions. 

In  the  different  forms  of  rheumatism — chronic,  articular, 
muscular,  blemiorrhagic.  and  senile  arthritis — the  sedative 
action  of  the  luminous  radiant  heat  in  the  alleviation  of 
pain  is  very  marked,  while  the  inability  to  move  the  affected 
limb  gradually  disappears. 

Bruises,  Sprains,  etc. — In  the  treatment  of  these  affections 
luminous  radiant  heat  has  proved  of  signal  service,  especially 


GENERAL  PRINCIPLES  15 

for  football  players,  by  whom  it  has  been  extensively  and 
most  successfully  used. 

Phlebitis. — In  cases  of  phlebitis,  even  where  the  cedema- 
tous  swelling  is  at  a  chronic  stage,  radiant  heat  treatment 
is  excellent.  After  a  single  bath  there  is  a  marked  reduction 
in  the  size  of  the  part  affected,  while  continued  applications 
result  in  the  normal  condition  being  restored. 

Rheumatoid  Arthritis. — Douglas  Kerr  found  that  at  the 
initial  stage,  even  at  the  time  when  the  attacks  are  most 
acute,  there  is  a  rapid  improvement  in  the  flexibility  of 
the  joints  and  in  the  general  condition  of  the  patient,  who 
not  infrequently  gains  in  weight  during  the  course  of  treat- 
ment. At  a  more  advanced  period,  when  the  joints  have 
become  deformed  and  there  is  a  cessation  of  pain,  the 
application  of  luminous  radiant  heat  is  of  itself  ineffectual, 
but  if  the  adhesions  are  broken,  either  gradually  or  suddenly, 
and  a  Riss  bath  taken  immediately  thereafter,  the  result 
is  a  considerable  diminution  of  the  deformity,  and,  after  sub- 
sequent baths,  some  recovery  of  the  flexibility  of  the  joints. 

Sciatica. — In  sciatica  the  results  are  often  at  variance 
with  one  another.  All  experience  a  considerable  amount 
of  relief  during  the  bath ;  some  are  quickly  cured,  while 
others,  on  the  contrary,  have  a  recurrence  of  sharp  and 
acute  pain.  These  differences  are  probably  to  be  accounted 
for  by  insufficient  diagnosis;  for  instance,  it  is  known  that, 
whatever  be  the  form  of  treatment,  the  same  results  are  not 
obtained  in  cases  of  neuralgic  as  in  those  of  neuritic  sciatica. 

Nephritis. — The  utility  of  the  radiant  heat  bath  in  cases 
of  nephritis  consists  in  the  profuse  perspiration  which  it 
induces,  thus  relieving  the  work  of  the  kidneys. 

General  Affections,  such  as  obesity,  anaemia,  general 
debility,  and  predisposition  to  rheumatic  affections,  are  all 
beneficially  influenced  by  the  action  of  luminous  radiant 
heat  on  the  functions  of  nutrition,  respiration,  and  perspira- 
tion. It  has  also  been  shown  that  the  luminous  rays  increase 
the  number  of  the  red  corpuscles  in  the  blood  and  their 
power  of  oxygenation. 


16          MANUAL  OF  PHYSIO-THERAPEUTICS 

SUMMARY. 

The  physiological  action  of  the  radiant  heat  bath  may 
be  briefly  summarized  thus : 

1 .  Very  marked  redness  of  the  skin. 

2.  Very  abundant  perspiration  and  the  elimination  of 
considerable  quantities  of  carbonic  acid  by  the  lungs. 

3.  Acceleration  of  the  pulse  and  increase  of  temperature ; 
these  two  phenomena  are  less  marked  in  proportion  than 
in  the  Turkish  bath. 

4.  Increase  of  the  volume  of  solid  materials  of  the  urine, 
especially  of  the  urea  and  uric  acid. 

5.  Greater  activity  of  the  functions  of  general  nutrition, 
and  the  elimination  of  organic  oxidation  products. 

6.  Penetrating  power   of   the   heat   rays   much   greater 
than  that  of  obscure  heat. 

7.  Marked  excitation  of  the  skin  by  the  chemical  rays, 
which  possess  pronounced  bactericidal  properties. 

8.  Special  action  of  the  luminous  rays  on  the  red  corpuscles 
of  the  blood,  augmenting  their  number,  and  thus  increasing 
their  power  of  oxygenation. 

The  Dowsing  Radiant  Heat  Baths.— In  1896  H.  J. 
Dowsing,  an  electrical  engineer,  invented  an  apparatus 
which  transformed  electricity  in  vacua  into  radiant  heat. 

Special  electric  lamps  constituted  the  source  of  luminous 
radiant  heat.  The  electric  lamp  is  formed  of  a  filament 
contained  in  vacuo  within  specially  prepared  glass  bulbs, 
or  tubes  of  various  shapes,  according  to  requirements. 
They  are  equally  suitable  for  either  continuous  or  alter- 
nating currents,  and  for  any  voltage.  Instead  of,  as  in 
ordinary  lamps  used  for  lighting  purposes,  producing  light 
without  appreciable  heat,  powerful  heat  rays  as  well  as 
light  rays  are  emitted.  The  heat  rays  are  of  such  intensity 
that  a  thermometer  placed  between  two  lamps  provided 
with  reflectors,  and  separated  by  a  distance  of  some  sixteen 
inches,  registers  almost  immediately  about  204°  C.  The 
electric  current,  before  reaching  the  lamps,  passes  through 
a  variable  resistance,  which  serves  as  a  regulator,  by  means 
of  which  any  desired  temperature  may  be  obtained. 


GENERAL  PRINCIPLES 


17 


The  lamps  are  fixed  in  highly  burnished  reflectors  of  suit- 
able formation,  and  are  easily  adjustable  to  any  position 
necessary  to  direct  the  luminous  radiant  heat  rays  either 
on  any  desired  part  or  on  the  whole  of  the  body  (see 
Figs.  3,  4,  5).  The  curve  of  the  surface  of  reflection  must 
be  such  that  the  heat  rays  emanating  from  the  lamps  are 
prevented  from  striking  against  the  glass;  otherwise,  owing 
to  the  very  high  temperature  obtained,  the  lamp  might 
be  injured. 

The  appliances  thus  permit  of  the  application  of  luminous 
radiant  heat  as  already  mentioned : 


FIG.  3. — DOWSING  LUMINOUS  HEAT  APPARATUS. 

(a)  By  direct  radiation  without  heating  the  surrounding 

air. 
(&)  By    diffusion    in    an    enclosed    space    automatically 

ventilated,    thus    heating    the    air    within    such 

enclosed  space. 
(c)  By  the  utilization  of  certain  determined  radiations 

to  the  exclusion  of  others. 

Appliances  for  Direct  Radiation  without  Heating  the  Sur- 
rounding Atmosphere. — One  or  more  Dowsing  lamps  are 
mounted  with  reflectors,  which,  by  the  diversity  of  their 
forms,  permit  of  the  limitation  of  their  radiation  activity 

2 


18          MANUAL  OF  PHYSIO-THERAPEUTICS 

to  certain  parts  of   the  body,  to  more  or  less  extended 
portions,  or  to  the  whole  of  the  body. 

The  reflectors,  mounted  on  a  vertical  and  movable  stand, 
can  be  fixed  at  different  heights.  One  can  thus  easily  direct 
the  luminous  radiant  heat  rays  on  any  part  of  the  body  of  a 
patient  sitting,  standing,  or  reclining  (Fig.  4).  There  being 
nothing  in  the  nature  of  an  enclosure,  and  the  temperature 
of  the  room  being  in  no  way  raised,  the  patient  breathes 
the  normal  atmosphere — a  point  of  no  inconsiderable  advan- 
tage. This  method  of  treatment  is  comparable  to  a  sun 
bath,  with  the  added  convenience  that,  by  means  of  a 


FIG.  4. — DIRECT  RADIATOR  APPLIED  TO  BACK  OF  THE  NECK. 

rheostat  attached  to  the  appliance,  the  intensity  of  the  heat 
can  be  increased  or  decreased  as  may  be  required  or  desired. 
Appliances  for  Diffusion  of  Luminous  Radiant  Heat  in  an 
Enclosed  Space. — The  lamps,  fitted  with  special  reflectors, 
are  fixed  in  an  enclosed  space,  varying  in  size  and  arrange- 
ment according  as  the  treatment  is  required  for  only  a  part 
or  for  the  whole  of  the  body  (Fig.  3).  It  must  not  be 
understood  by  the  term  "  enclosed  space  "  as  here  used  that 
the  circulation  of  the  outer  air  is  completely  suppressed 
Perfect  ventilation  is  necessary,  and  is  secured,  in  order  to 
eliminate  as  much  as  possible,  and  as  soon  as  formed,  the 
perspiration  from  the  body  brought  about  by  the  very  high 


GENERAL  PRINCIPLES  19 

temperature  to  which  the  patient  is  subjected;  the  auto- 
matic ventilation  provided  in  the  Dowsing  apparatus  is 
amply  sufficient  to  keep  the  patient's  skin  perfectly  dry. 

There  are  also  appliances  for  administering  the  heat 
by  direct  radiation  without  raising  the  temperature  of  the 
atmosphere  surrounding  the  body. 

The  complete  body  bath  consists  of  a  bed  fitted  with 
asbestos  lined  mattress  and  blanket,  and  having  five  re- 
flectors, each  containing  two  Dowsing  lamps,  with  rheostat 
for  regulating  the  current.  The  reflectors  are  fixed  on 
metal  rods,  easily  movable,  supported  by  standards  resting 


FIG.  5. — LOCAL  RADIANT  HEAT  CABINET. 

on  the  floor  or  fixed  to  the  sides  of  the  bedstead.  The 
patient,  being  undressed,  lays  himself  upon  the  mattress, 
and  is  covered  with  the  asbestos-lined  blanket,  and  the 
head  only  being  exposed,  the  patient  breathes  the  normal 
atmosphere  of  the  room.  The  current  is  then  turned  on, 
and  by  means  of  the  rheostat  the  air  within  the  enclosed 
space  is  brought  up  to  the  requisite  temperature.  The 
local  baths  for  the  various  limbs  are,  of  course,  on  a  smaller 
scale,  and  are  made  of  special  shapes  for  treating  deformed 
limbs,  etc.  The  apparatus  for  the  leg  or  foot  can  be  placed 
on  a  stand  of  suitable  height,  while  that  for  the  upper  limbs 
is  fixed  on  a  stand  which  can  be  adjusted  in  any  direction. 
In  all  local  baths,  when  using  the  asbestos-lined  blanket, 


20 


MANUAL  OF  PHYSIO-THERAPEUTICS 


the  luminous  radiant  heat  acts,  not  only  by  radiation,  but 
also  by  superheating  the  air  in  the  enclosed  space;  other- 
wise the  radiation  is  direct,  without  in  any  way  affecting 
the  temperature  of  the  surrounding  atmosphere. 

For  all  local  applications  other  than  of  the  limbs,  the 
apparatus  or  appliance  consists  of  a  lamp  and  reflector 
attached  to  a  movable  stand,  the  arrangement  of  which 
is  such  that,  by  means  of  swivels  and  ball-and-socket  joints, 
the  reflectors  may  be  moved  and  the  rays  readily  directed 
on  any  part  of  the  body. 


FIG.  6. — GREVILLE  GENERATOR  FOR  WHOLE  BODY. 

Appliances  for  the  Utilization  of  Certain  Determined 
Radiations  to  the  Exclusion  of  Others.- — For  this  purpose  a 
contrivance  in  the  nature  of  a  highly  burnished  metallic 
cone  is  used,  within  which  is  placed  a  Dowsing  lamp  so 
arranged  that  the  rays  are  concentrated  at  the  apex,  where 
screens  of  various  colours  can  be  fixed  to  allow  the  modified 
rays  to  pass.  A  red  glass  screen  stops  the  chemical  rays, 
and  an  alum  solution  cuts  off  the  heat  rays.  A  solution  of 
sulphate  of  copper  held  between  two  crystal  glass  plates 
will  allow  chemical  rays  only  to  pass.  This  is  a  feature  in 
therapeutics  which  is  still  in  its  infancy,  and  it  is  well  worth 


GENERAL  PRINCIPLES  21 

the  attention  of  medical  men.  The  remarkable  results 
obtained  by  the  late  N.  R.  Finsen,  of  Copenhagen,  tend  to 
show  that  much  may  yet  be  expected  from  it. 

The  Greville  Electro-thermic  Generators. — These  appar- 
atus are  usually  made  of  aluminium,  and  are  designed  for 
treatment  of  the  whole  body  (with  the  exclusion  of  the 
head),  or  any  region  in  particular  (Fig.  6);  indeed,  one 
of  the  main  features  of  the  system  is  the  ease  with  which 
heat  may  be  applied  to  any  portion  of  the  body  affected. 
The  heat  is  produced  by  the  flow  of  electricity  through 
sections  of  naked  wire  made  of  a  non-oxidizable  metal 
or  compound  of  metals.  The  wires  (arranged  like  harp 
strings)  are  wound  upon  porcelain  insulators  attached 
to  the  back  of  the  generator,  while  the  front  or  inner  side 
is  of  perforated  sheet  aluminium.  A  temperature  of  200°  to 
250°  C.  is  easily  obtainable,  and  is  under  absolute  control. 
The  electric  current  may  be  taken  from  the  ordinary  light- 
ing mains  or  from  accumulators. 

In  this  system  the  rays  convected  from  the  naked  wires 
are  of  heat  giving  properties  only.  In  fact,  the  main 
difference  between  the  Greville  and  the  Dowsing  radiant 
heat  baths  is  that  in  the  former  the  invisible  rays  beyond 
the  red  in  the  spectrum  are  alone  used,  while  in  the  latter 
the  light  rays  are  used.  These  ultra-red  rays  have  been 
found  to  contain  the  maximum  amount  of  heat,  and  no 
injurious  chemical  rays  are  permitted  to  enter  the  generator. 


CHAPTER  II 
HOT-AIR,  STEAM,  AND  TURKISH  BATHS 

The  Hot-Air  Cabinet  Bath. 

THE  essential  difference  between  this  and  the  Turkish 
bath  is  that  the  head  is  excluded  from  contact  with  the 
hot  air,  so  that  the  whole  body  is  exposed  to  dry  super- 
heated air,  while  the  patient  breathes  in  a  comparatively 


FIG.  7. — HOT-AIR  CABINET  HEATED  BY  ELECTRICAL 
EESISTANCE  WIRES. 

cool  atmosphere.  Many  portable  and  inexpensive  forms  of 
the  bath  are  sold,  made  of  waterproof  cloth  stretched  on 
a  wooden  or  metal  frame,  and  these  are  often  perfectly 
efficacious.  There  are  also  more  elaborate  wooden  cabinets 
constructed,  lined  with  zinc  or  cork  (Fig.  7). 

22 


HOT-AIR,  STEAM,  AND  TURKISH  BATHS       23 

Electricity  is  the  most  suitable  means  to  heat  the  air, 
because  the  temperature  is  easily  under  control,  and  can 
be  increased  up  to  about  150°  C.  (the  exact  amount  can 
be  read  off  on  a  thermometer).  The  air  is  quite  dry,  and 
not  vitiated  by  any  vapours  of  burning  gas  or  oil,  and  the 
patient  breathes  air  of  ordinary  temperature. 

The  heat  is  generated  by  the.  electric  current  passing 
through  suitable  resistance  wires,  which  are  wound  over 
porcelain  frames  so  that  the  air  has  free  access.  A  smaller 
or  greater  number  of  these  electric  stoves  can  be  switched 
on  to  regulate  the  temperature. 

The  cabinets  are  made  either  for  the  whole  body  or 
only  for  an  arm  or  leg.  Other  sources  of  heat  employed 
are  small  gas  stoves,  spirit  lamps,  steam  coils,  or  paraffin 
stoves.  Some  of  these  are  not  free  from  risk,  and  more 
than  one  patient  has  been  severely  burnt.  The  electric 
method  or  the  steam  coil  is  certainly  the  best.  If  a  lamp 
or  stove  be  used,  it  must  be  lighted  before  the  patient  enters 
the  bath.  The  bath  may  be  administered  to  a  patient  in 
bed  by  using  a  special  frame  and  covering,  under  which  a 
tin  pipe  is  led  to  conduct  the  hot  air.  This  is  a  common 
hospital  device. 

The  temperature  of  the  bath  should  vary  from  65°  C.  to 
120°  C.,  and  the  duration  may  be  from  six  minutes  to  one 
hour,  according  to  circumstances.  The  maximum  beneficial 
effects  can  be  obtained  in  the  generality  of  cases  in  thirty 
to  forty  minutes. 

Before  entering  the  bath,  the  patient  should  remove  all 
his  clothing,  and  wrap  up  in  a  blanket  or  large  Turkey  bath 
sheet  while  waiting.  Before  and  during  the  bath,  water, 
hot  or  cold,  should  be  freely  drunk.  The  head  should  be 
enveloped  in  a  cool,  damp  cloth. 

On  leaving  the  bath,  the  patient  is  given  a  spray  or  rain 
douche,  and  if  necessary  a  vigorous  reaction  insured  by 
friction.  In  rheumatic  cases  it  is  sometimes  well  to  prolong 
the  perspiration  in  a  gentle  form  by  enveloping  the  patient 
with  warm  blankets,  and  merely  finish  off  with  a  cool 
sponging. 


24 


MANUAL  OF  PHYSIO-THERAPEUTICS 


THERAPEUTIC  INDICATIONS. 

Hot  air  is  of  great  value  in  the  treatment  of  obesity,  uric 
acid  diathesis,  fatty  glycosurics,  neurasthenia,  or,  indeed,  any 
auto-intoxication.  Many  organic  forms  of  chronic  nervous 
disease,  as  locomotor  ataxia,  are  materially  benefited  by 
the  use  of  hot-air  baths,  even  though  we  admit  that  cure 
is  out  of  the  question.  Various  anaemias  also  are  helped, 
care  being  taken  not  to  employ  too  high  a  temperature 
or  unduly  prolong  the  bath. 

All  morbid  conditions  dependent  on  congestion  of  the 
various  internal  organs  are  improved  by  judicious  employ- 
ment of  this  bath.  In  actual  hyperpyesis  particular  care 


FIG.  8. — THE  STEAM  CABINET. 

is  necessary  in  prescribing  it,  however,  and  the  head  should 
be  invariably  kept  cool  by  means  of  an  ice-bag  or  towel 
wrung  out  of  ice-cold  water. 

The  Steam  Cabinet  Bath. 

This  is  identical  with  the  Russian  vapour  bath,  except 
that,  instead  of  being  shut  in  a  room  into  which  the  steam 
is  introduced,  the  patient  sits  in  a  cabinet  with  his  head 
excluded  (Fig.  8). 

The  cabinet,  usually  made  of  wood,  should  be  practically 
steam-tight.  The  steam  may  be  generated  in  the  cabinet 
itself  or,  which  is  better,  conveved  from  an  outside  source. 


HOT-AIR,  STEAM,  AND  TURKISH  BATHS       25 

The  patient  may  be  vertical  or  horizontal,  and  sits  or 
lies  on  a  latticed  wooden  seat,  under  which  run  pipes  with 
small  perforations  by  means  of  which  the  steam  enters. 
The  temperature  of  the  bath  rises  in  direct  proportion  to 
the  rapidity  with  which  the  steam  enters.  The  temperature 
desirable  is  from  40°  to  46°  C.  The  patient  can  tolerate 
higher  temperatures  after  a  series  of  baths.  No  sensation 
of  burning  is  experienced  when  once  free  diaphoresis  has 
been  established.  As  in  all  such  procedures,  the  head 
of  the  patient  must  be  enveloped  in  a  damp  towel.  Dia- 
phoresis is  hastened  and  increased  if  water  be  freely 
drunk. 

On  leaving  the  cabinet,  the  patient  should  have  a  spray 
or  rain  bath,  beginning  with  water  at  30°  C.  and  cooling 
down  to  15°  or  12°  C. 

Duration  of  the  Bath. — On  the  average  from  fifteen  to 
thirty  minutes.  Brief  exposures  of  two  to  five  minutes 
are  employed  as  a  preliminary  to  a  Turkish  bath  or  cold 
stimulating  applications.  Baths  of  over  thirty  minutes' 
duration  should  not  be  employed  except  in  the  case  of  very 
robust  patients. 

Physiological  Effects. — After  a  short  application  the 
cutaneous  vessels  become  dilated  and  the  body  surface 
warm.  In  five  or  six  minutes  perspiration  begins,  and 
the  skin  reddens.  The  body  temperature  rises,  respiration 
and  pulse  are  accelerated,  and  metabolism  is  increased.  The 
white  blood-corpuscles  are  almost  always  increased,  but 
the  red  diminish,  unless  a  relative  increase  takes  place 
owing  to  inspissation  of  blood  from  much  fluid  loss.  There 
is  loss  of  body- weight,  varying  with  the  duration  of  exposure, 
and  often  amounting  to  several  pounds. 

THERAPEUTIC  INDICATIONS. 

Brief  baths  are  employed  in  anaemia  and  neurasthenia, 
while  more  prolonged  baths  are  of  service  in  various  constitu- 
tional dyscrasia,  in  rheumatic  affections,  uric  acid  diathesis, 
chronic  renal  disease,  and  in  various  skin  affections,  such  as 
psoriasis.  In  common  colds,  chills,  and  febrile  affections,  the 
diaphoresis  induced  is  also  useful. 


26 


MANUAL  OF  PHYSIO-THERAPEUTICS 


Generally  speaking,  febrile  diseases  are  a  counter- 
indication,  as  are  also  organic  nervous  diseases  (if  we  exclude 
some  of  the  parasyphilides  at  an  early  stage,  and  chronic 
arterial  degeneration). 


5   -3 
a  o 


ThejTurkish  Bath. 

The  Turkish  bath  is  a  very  ancient  procedure,  and  dates 
from  the  time  of  the  Roman  Empire.  To-day,  in  various 
parts  of  Italy,  in  Rome  and  elsewhere,  the  ruins  of  such 


HOT-AIR,  STEAM,  AND  TURKISH  BATHS       27 

baths,  used  in  the  time  of  Nero,  may  be  seen.  In  Jerusalem 
a  bath  of  this  nature,  built  at  the  time  of  Herod,  is  still  used 
regularly,  after  nearly  two  thousand  years  have  elapsed. 
Practically  every  nation  and  country  has  some  peculiar 


It 

PS   '3 


O       C3 

O     x 

I 


form  of  a  "  sweating  bath,"  some  of  which  are  extremely 
dirty  and  unpleasant.  Probably  the  Turkish  bath  is  the 
most  elaborate  and  luxurious  type  of  this  variety  of  bath. 
In  the  modern  form  it  consists  of  a  series  of  rooms  comprising 
at  least  the  following  compartments : 


28  MANUAL  OF  PHYSIO-THERAPEUTICS 

1.  The  Tepidarium,  a  room  heated  to  a  temperature  of 
54°  to  72°  C. 

2.  The  Calidarium,  a  room  heated  to  a  temperature  of 
65°  to  93°  C.     In  some  cases  there  is  an  annexe  to  this 
apartment  heated  up  to  120°  to  150°  C.,  but  in  smaller 
suites  this  is  usually  dispensed  with  (Fig.  9). 

3.  The  Shampoo  Room,  which  is  furnished  with  marble 
slab,  douche  apparatus,  etc.,  and  attached  to  this  room 
is  frequently  found  a  plunge  or  swimming  bath  at  a  tem- 
perature of  12°  to  15°  C.  for  the  more  vigorous  patients 
to  use  as  a  final  measure  in  cooling. 

4.  The  Cooling  and  Dressing  Room,  with  suitable  couches 
for  patients  to  rest  on  from  forty  minutes  to  one  hour  after 
a  bath  (Fig.  10). 

The  rooms  are  heated  by  means  of  a  furnace,  or  indirectly 
by  a  steam  heater.  Ample  provision  must  be  made  for 
ventilation,  for  inefficiency  in  this  respect  will  cause  much 
oppression  and  headache  to  those  using  the  bath.  The 
outlet  for  foul  air  should  be  near  the  bottom  of  the  room, 
communicating  with  a  ventilating  shaft.  If  heated  by  hot 
air,  the  opening  for  its  admission  is  best  placed  at  a  point 
two  or  three  feet  above  the  level  of  the  floor. 

Technique. — The  patient,  having  removed  all  his  clothing 
with  the  exception  of  the  loin  cloth  demanded  by  modesty, 
drinks  a  glass  of  water  and  lies  down  on  a  couch  in  the 
tepidarium.  A  moist  cloth  is  often  placed  around  the 
head.  The  time  which  elapses  before  the  onset  of 
perspiration  varies  greatly  in  different  subjects,  but,  on 
an  average,  some  moisture  appears  on  the  skin  in  from 
ten  to  fifteen  minutes,  and  very  soon  the  patient  is  per- 
spiring profusely.  When  perspiration  is  slow,  the  activity 
of  the  skin  is  increased  by  the  brisk  application  of  friction 
gloves. 

Two  or  three  minutes  spent  in  the  Russian  bath  or  steam- 
box  prior  to  entering  the  Turkish  soften  the  skin  and 
facilitate  a  good  sweat.  The  feet  may  further  be  placed 
in  a  hot  foot  bath  and  hot  water  freely  imbibed.  Such 
patients  as  do  not  perspire  even  with  these  adjuvants 
usually  experience  a  good  deal  of  oppression  and  discomfort; 
the  skin  becomes  very  dry  and  hot,  and  they  should  be 


HOT-AIR,  STEAM,  AND  TURKISH  BATHS       29 

removed  from  the  bath,  or  they  may  become  seriously 
upset.  These  cases,  however,  are  the  exception. 

Perspiration  having  been  properly  established,  the 
calidarium  or  second  room  may  be  entered,  and  profuse 
perspiration  allowed  for  about  ten  minutes.  Many 
people  are  unable  to  stand  the  intense  heat  of  the 
third  room  even  for  a  few  minutes,  but  hardened  veterans 
enjoy  it. 

A  suitable  amount  of  diaphoresis  having  taken  place, 
the  patient  enters  the  shampoo  room  and  lies  down  on 
the  slab.  He  is  briskly  massaged  from  head  to  foot,  much 
superficial  epidermis,  already  loosened  by  the  perspiration, 
being  thus  removed.  Lathering  follows,  hot  soapsuds  being 
ladled  on  to  the  skin  and  well  rubbed  in  with  a  loofah, 
preferably  brought  by  the  patient,  so  as  to  avoid  the 
possibility  of  infection.  The  shampooing  is  a  most  comfort- 
ing process,  and  is  continued  until  the  skin  feels  smooth 
and  polished.  A  douche  or  spray  douche,  from  25°  C.  down 
to  15°  C.,  or  even  lower,  is  now  applied.  This  has  a  tonic 
effect,  and  also  serves  to  completely  remove  the  soapsuds. 
The  plunge  bath  may  be  taken  or  omitted,  according  to 
circumstances,  and  then  the  patient,  wrapped  in  a  warm 
sheet,  lies  down  in  the  cooling  room  until  the  pulse  is  normal 
and  the  skin  thoroughly  dry.  A  cup  of  coffee  at  this  stage  is 
beneficial  and  refreshing  in  many  cases. 

Where  the  object  is  reduction  of  weight,  a  daily  Turkish 
bath  up  to  one  hour  in  duration  may  be  employed;  but 
for  the  average  person  three  a  week  are  amply  sufficient, 
and  with  feeble  patients  these  must  be  of  brief  duration. 

Physiological  Action. — The  sweat  glands  are  powerfully 
stimulated,  and  the  amount  of  secretion  may  rise  from 
the  normal  l|  ounces  per  hour  to  several  pounds  per  hour. 
A  loss  of  2  pounds  in  weight  is  quite  common  after  a  full 
Turkish  bath.  Unless  the  patient  drink  water  freely,  the 
blood-volume  will  be  considerably  reduced  in  these  circum- 
stances and  cardiac  enfeeblement  result.  Blood  is  with- 
drawn from  liver,  spleen,  and  all  the  internal  organs,  and 
the  absorption  of  fluid  from  the  intestines  which  takes 
place  leads  to  subsequent  constipation  in  some  cases. 

By  the  inhalation  of  the  hot  air  the  pulmonary  mucous 


30  MANUAL  OF  PHYSIO-THERAPEUTICS 

membrane  is  excited  to  secretion  to  some  extent,  rapid 
volatilization  occurring.  The  respiration  is  mainly  thoracic. 
The  cardiac  beats  quicken  and  the  mean  blood  pressure 
rises  soon  after  the  bath  is  entered,  and  some  fulness  in 
the  head  and  discomfort  may  be  experienced,  lessened  by 
the  foot  bath  mentioned  above.  The  mean  blood-pressure 
falls  and  the  pulsevslows  with  the  onset  of  perspiration.  The 
rise  in  body-temperature  is  so  slight  as  to  be  negligible 
in  the  majority  of  cases.  In  very  obese  persons  this  may 
not  be  the  case,  however,  as  the  heat  loss  in  such  cases  is 
not  proportionate  to  the  heat  gain.  Kellogg  points  out 
that  such  patients  have  much  smaller  skin  surface  in  pro- 
portion to  their  weight  than  spare  individuals. 

THERAPEUTIC  INDICATIONS. 

These  are  practically  the  same  as  the  hot-air  bath, 
but  the  Turkish  bath  cannot  be  employed  for  many  cases 
for  which  the  hot-air  bath  is  quite  advisable.  It  is  contra- 
indicated,  e.g.,  in  arterio-sclerotic  conditions, cardiac  asthma 
and  dilatation,  exophthalmic  goitre,  in  patients  with 
unusually  high  blood-pressure,  and  in  advanced  renal 
disease. 

The  Tyrnauer  Apparatus. 

It  is  claimed  for  this  apparatus  that  the  air  enclosed  is 
uniform  in  temperature,  a  condition  quite  unusual  in  hot- 
air  apparatus.  Indeed,  in  some  machines  of  this  character 
there  may  be  a  difference  of  as  much  as  37°  C.  between 
different  parts,  depending  on  the  source  of  the  heating 
This,  in  the  Tyrnauer  apparatus,  consists  in  electrical 
resistance  wires  lying  in  a  trough  beneath  the  apparatus. 
A  temperature  of  80°  to  95°  C.  can  be  attained  in  five  to 
six  minutes,  and  as  high  as  148- 7J  C.  in  ten  minutes.  The 
temperature  is  also  absolutely  under  the  control  of  the 
person  manipulating  the  machine,  and  can  be  quickly 
reduced  or  raised.  The  machine  is  made  of  oak  or  mahogany, 
with  metal  such  as  copper  or  nickel,  and  lined  with  asbestos. 
There  are  three  separate  sources  of  heat,  and  any  one  of 
them  can  be  readily  turned  off  or  on.  The  regulation  of  the 


HOT-AIR,  STEAM,  AND  TURKISH  BATHS       31 

temperature  is  further  controlled  by  the  use  of  a  perforated 
asbestos  screen,  which  can  be  raised  or  lowered  to  lessen 
the  degree  of  radiation  from  the  sources  of  heat.  The 
resistance  wires  rest  on  a  "poilite  "  asbestos  tile  or  plate, 
and  are  regulated  by  switches.  Double  fuses  guard  against 
damage  from  a  ' '  short."  A  thermometer  is  fixed  in  a  prom- 
inent position  so  that  both  the  patient  and  the  attendant 
can  read  it.  The  amount  of  current  used  varies  from  5  to 
18  amperes,  and  an  ordinary  treatment  uses  up  about  4d. 
to  5d.  worth  of  current.  There  are  various  apparatus  for 
different  parts  of  the  body,  like  the  Greville,  and  the  local 
parts  are  particularly  well  adapted  to  the  different  parts  for 
which  they  are  designed.  All  the  external  surfaces  of  the 
joints  are  treated.  This  is  a  distinctly  thermotherapeutic 
measure  as  opposed  to  a  light  treatment,  and  in  no  way 
compares,  e.g.,  with  the  leucodescent  lamp.  It  is  cfarfcheat. 
The  apparatus  is  about  the  most  costly  of  any  of  these, 
and  has  an  additional  drawback — German  origin.  One  has 
been  in  use  for  a  number  of  years  at  the  London  Hospital 
with  considerable  success,  and  also  at  Llandrindcd  Wells. 

Baths  (Berthe  Apparatus). 

This  apparatus  has  been  in  use  for  many  years  at  Vichy 
and  later  at  Harrogate.  It  is  a  valuable  method  of  treating 
gout,  rheumatism,  sciatica,  and  other  forms  of  neuritis.  It 
is  a  very  strongly  built  chamber  made  of  mahogany  and 
copper,  and  by  means  of  it  the  following  treatments  can  be 
given : 

(A)  1.  Dry  hot  air.     2.  Steam.     3.  Medicated  vapours 
(terebinth,    menthol,    and    wintergreen).     4.    Oxygen    and 
CO2  gas  for  the  whole  body. 

(B)  The  separate  treatment  of  the  arm,  leg.  or  feet  by 
local  baths. 

(C)  To  keep  the  temperature  of  the  bath  hotter  at  the  feet 
than  the  head  a  specially  controlled  system  of  ventilation 
renews  the  air  in  the  bath  and  removes  excreted  matter  as 
it  is  emanated. 

(E)  The  temperature  of  the  air  can  be  kept  constant  or  it 
can  be  altered  at  will. 


32          MANUAL  OF  PHYSIO-THERAPEUTICS 

(F)  The  chamber  can  be  disinfected  completely  and  in- 
stantly by  means  of  antiseptic  vapours  such  as  thymol  and 
formalin. 

Treatment  may  be  administered  with  or  without  medi- 
cated additions,  nasal  or  pharyngeal  douches,  or  inhalation, 
which  can  be  taken  during  the  bath.  A  thermometer  is  so 
fitted  as  to  allow  the  bather  to  note  the  exact  temperature 
of  the  bath  at  any  moment,  and  the  patient  can  leave  the 
bath  unaided  at  any  moment  provided  he  is  not  so  crippled 
as  to  need  crutches  and  arm  help.  The  hot  chamber  is 
closed  at  the  upper  part  by  means  of  a  collarette  padded 
with  rubber,  allowing  the  patient  the  utmost  range  of 
comfort;  he  can  use  his  hands  for  holding  a  book  or  news- 
paper. A  seat  is  fitted  which  can  be  automatically  regu- 
lated to  the  size  and  configuration  of  the  patient. 


CHAPTER  III 
PHOTOTHERAPY 

IT  has  been  shown  that  sunlight  is  made  up  of  various  kinds 
of  rays,  and  the  existence  of  the  following  have  been  clearly 
demonstrated:  (1)  Heat  rays;  (2)  light  rays;  (3)  chemical 
or  actinic  rays. 

The  heat  rays,  although  invisible,  make  a  powerful  im- 
pression on  the  cutaneous  nerves.  They  are  found  in  the 
red  portion  of  the  spectrum ;  while  the  light  rays  are  in  the 
yellow  portion,  and  the  chemical  rays  in  the  violet  and 
ultra  violet  portions.  Chemical  rays  are  invisible,  but  act 
on  the  skin.  By  various  devices  any  of  these  elements  in 
a  sunlight  ray  may  be  picked  out  or  eliminated. 

The  electric  arc  light  and  sunlight  are  very  similar,  the 
former  containing  more  actinic  or  chemical  rays  in  beams 
of  equal  luminosity.  The  incandescent  light  contains  a 
large  portion  of  heat  rays.  The  effects  of  exposure  to  light 
are  due  chiefly  to  the  action  of  the  chemical  and  thermal 
rays.  The  powerful  effect  of  light  on  plant  life  is  shown 
by  the  manner  in  which  plants,  leaves,  or  flower-stalks  bend 
towards  the  origin  of  the  light  in  their  growth.  Light 
rays  are  powerful  for  good  or  ill,  however,  and,  as  is  well 
known,  concentrated  sunlight  will  scorch  and  destroy  plant 
life. 

On  animal  life  the  action  of  the  chemical  rays  is  well 
demonstrated  in  sunburn  in  man,  and  the  darkening  of  the 
white  coat  of  animals  long  exposed  to  sunlight.  The  pig- 
ment in  the  skin  of  races  resident  in  tropical  zones  is  largely 
a  protective  measure. 

Action  of  Light  on  Metabolic  Processes. — The  output  of 
C0.2  is  increased  in  all  animals  when  exposed  to  light;  all 
tissue  changes  are  more  rapid,  and  if  food  be  withheld 
more  weight  is  lost  in  daylight  than  in  the  dark.  Tho 
metabolic  processes  of  prisoners  confined  in  solitary,  dark- 

33  3 


34          MANUAL  OF  PHYSIO-THERAPEUTICS 

ened  cells,  fed  on  a  scanty  supply  of  bread  and  water,  are 
sluggish  in  the  extreme,  with  resultant  mental  depression 
and  sense  of  humiliation.  This  also  has  much  to  do  with 
the  occurrence  of  cretinism  in  the  deep,  sunless  valleys  of 
Switzerland. 

Tissue  oxidation  is  unquestionably  increased  by  sunlight 
in  all  living  creatures,  and  in  the  human  species  this  is  due 
to  reflexes  set  up  by  the  stimulation  by  light  rays  of  the 
nerve  endings  in  the  skin. 

Exposure  to  powerful  sunlight  causes  headache  and 
vertigo,  due  to  too  powerful  stimulation  of  the  optic  nerve; 
similar  results  are  seen  after  prolonged  exposure  of  the 
naked  trunk.  Black  races  are  protected  against  the  actinic 
or  chemical  rays  by  the  pigment  in  their  skin,  which  is 
impenetrable  to  these  rays,  and  a  white  man  can  acquire 
temporary  immunity  similarly  by  the  application  of  some 
black  water  paint. 

Sunstroke  is  of  course  due  to  over-exposure  of  the  central 
nervous  system,  head  or  neck  being  insufficiently  covered, 
to  strong  sunlight.  In  Europeans,  a  very  brief  exposure 
suffices,  but  in  the  native  races  some  immunity  is  acquired 
by  the  nervous  system  becoming  so  far  habituated  to  the 
special  stimulus.  In  India  it  is  not  uncommon,  even  at 
noon,  to  see  natives  stretched  on  the  ground  asleep,  abso- 
lutely unprotected  against  a  scorching  sun. 

The  functions  of  the  skin  are  all  stimulated  by  such 
exposure  to  the  sun's  rays,  irrespective,  to  some  extent, 
of  the  temperature  of  the  surrounding  air.  Profuse  per- 
spiration is  induced  by  the  action  of  the  chemical  and  the 
heat  rays,  the  latter  being  most  concerned.  Toxic  sub- 
stances in  the  blood  may  be  thus  got  rid  of,  but  further, 
light  has  a  most  powerful  germicidal  influence,  rapidly 
killing  parasites,  fungi,  and  several  of  the  more  virulent 
types  of  bacteria. 

Therapeutic  Application  of  Light. — (1)  Sunlight;  (2)  elec- 
tric light:  (d)  arc,  (b)  incandescent.  It  has  been  clearly 
demonstrated  that  the  nature  of  these  forms  of  light  is  the 
same,  irrespective  of  the  source,  although  the  latter  is  of 
importance  in  considering  the  questions  of  convenience 
in  practical  application  and  the  therapeutic  results. 


PHOTOTHERAPY 


35 


Sunlight  contains  all  these  types  of  rays  in  abundance; 
of  electric  lights,  the  arc  resembles  it  most.  The  incan- 
descent light  contains  about  90  per  cent,  of  heat  rays,  the 
balance  being  made  up  of  small  proportions  of  luminous 
and  chemical  rays.  In  this  country  this  bath  is  largely 
restricted  to  the  indoor  form,  owing  to  the  low  temperature 
prevailing  during  most  months  of  the  year. 

Formerly  there  was  a  large  open-air  sun  bath  at  Peebles, 
but  it  has  been  done  away  with,  and  patients  are  treated 
in  this  manner  on  a  flat  roof.  At  Battle  Creek  there  is  a 
large  one  combined  with  an  arenarium  or  sand  bath,  patients 
lying  about  in  the  warm  sand.  This  is  an  excellent  idea. 


The  Indoor  Sun  Bath. 

The  indoor  sun  bath  is  more  convenient  in  this  country, 
and  can  be  easily  arranged  given  a  south  exposure  and 


Fie.  11 SUN  BATH. 

sufficient    sunshine.     The    windows    must    be    kept    open, 
allowing  unrestrained  play  of  the  light,   as  the  valuable 


36 


MANUAL  OF  PHYSIO-THERAPEUTICS 


ultra  violet  rays  are  absorbed  by  the  glass.  The  patient's 
head  should  be  protected  by  a  moist  towel,  but  all  other 
clothing  or  covering  except  the  loin  cloth  demanded  by 
decency  may  be  dispensed  with.  Patients  with  tender, 
sensitive  skins  must  go  warily,  as  erythema  solare  is  easily 
produced,  and  is  very  irritating  if  not  painful.  The  duration 
of  the  bath  will  largely  depend  on  the  season  of  the  year  and 
the  prevailing  weather  conditions.  Three  minutes  is  very 
often  long  enough  to  start  with.  Caution  is  always  needful, 


...       '        ' 
FIG.  12. — OPEN-AIR  SUN  BATH  AND  ARENARIUM  (BATTLE  CREEK). 

for  too  long  exposure  will  cause  headache,  lassitude,  and 
depression  if  the  sun  be  hot,  and  possibly  a  severe  chill  or 
even  pneumonia  if  the  air  be  cold. 

Individuals  witli  dark  hair  and  complexion  are  less 
sensitive  to  the  influence  of  sunlight  than  fair,  blue-eyed 
people,  and  for  the  former  the  exposure  may  often  be  allowed 
for  half  an  hour  or  more  without  harm  resulting;.  Custom 


PHOTOTHERAPY 


37 


counts  for  a  great  deal,  too,  and  after  the  training  and 
toning  up  afforded  by  a  series  of  baths,  exposure  for  two  or 
three  hours  daily  can  often  be  tolerated  and  enjoyed.  The 
skin  usually  darkens  considerably,  from  increase  in  pigment. 

In  northern  temperate  latitudes  the  intensity  of  the 
sun's  rays  is  greatest  from  mid- June  to  mid -September, 
and  the  intensity  always  increases  with  the  altitude. 

After-Treatment. — At  the  conclusion  of  the  bath  the 
patient  should  be  taken  in  hand  by  an  attendant  and  given 


FIG.  13.— INDOOR  SUN  BATH. 

either  a  wet-sheet  rub  or  a  cooling  spray  or  douche,  or  in 
the  case  of  robust  and  vigorous  patients  a  plunge  and  short 
swim  is  a  beneficial  termination. 

Temperature  of  the  Patient. — The  patient's  temperature 
should  be  taken  immediately  before,  during,  and  after  the 
sun  bath.  The  temperature  usually  rises  from  0-5°  to  1°  C. 

In  individuals  who  perspire  freely  the  temperature 
usually  rises  but  slightly,  but  in  persons  with  dry  skins,  such 


38          MANUAL  OF  PHYSIO-THERAPEUTICS 

as  chronic  dyspeptics,  diabetics,  and  those  suffering  from 
extensive  scleroderma,  a  higher  temperature  is  soon  shown. 

Physiological  Effects. — The  reaction  induced  by  a  sun 
bath  represents  the  effect  of  the  combined  influence  of  the 
thermic,  luminous,  and  chemical  elements  of  the  sun's 
rays. 

The  heat  rays  elevate  the  body  temperature,  just  as  the 
hot  air  or  steam  do  in  the  hot-air  or  vapour  bath  cabinet, 
either  by  causing  an  accumulation  of  heat  or  preventing 
its  escape  by  radiation  and  evaporation.  All  the  organs 
of  the  body  are  stimulated,  and  the  metabolic  activity 
is  increased.  There  is  increased  oxidation  of  proteid 
substances,  increased  consumption  of  carbohydrates  and 
fats,  and  increased  output  of  CO.,  correspondingly.  The 
cutaneous  vessels  are  dilated,  the  sweat  glands  rendered 
more  active,  and  the  actual  amount  of  sweat  may  rise  from 
the  normal  average  of  If  ounces  per  hour  to  2  or  3  pounds, 
particularly  if  the  patient  is  taking  exercise  (vide  supra). 

The  blood  is  markedly  diverted  from  the  internal  organs 
to  the  skin  surface,  and  these  viscera  are  thus  decongested 
for  the  time  being.  The  patient  may  be  rendered  very 
drowsy  by  cerebral  anaemia. 

Finsen  has  shown  that  the  chemical  rays  are  equally 
active  as  regards  the  nervous  system,  and  have  a  markedly 
tonic  influence. 

THERAPEUTIC  INDICATIONS. 

It  will  be  at  once  seen  that  in  all  cases  with  defective 
metabolism  as  a  participating  cause  in  the  morbid  condition 
we  have  a  fair  mark  for  these  sun  baths.  Among  the  most 
common  of  these  are  dyspepsia,  diabetes,  obesity,  and  that 
congeries  of  symptoms  herded  together  under  the  term  so 
commonly  used  by  the  laity.  "  the  uric  acid  diathesis,"  with 
which  perhaps  uric  acid  has  very  little  to  do.  In  anaemic 
conditions  the  haemopoictic  centres  are  stimulated,  toxins 
are  eliminated,  and  an  accompanying  and  often  resultant 
neurasthenia  is  relieved.  In  some  forms  of  renal  disease, 
hepatic  congestion,  and  early  cirrhosis,  benefit  is  derived  very 
frequently.  In  tuberculous  conditions  an  early  improve- 
ment is  noticeable  when  the  climate  permits  of  the  sun  bath 


39 

forming  a  part  of  the  open-air  regime  now  so  generally 
employed. 

Even  skin  diseases  such  as  eczema  and  psoriasis  have  been 
found  to  benefit,  but  we  must  proceed  cautiously;  mixed 
bathing  with  such  cases  is  difficult,  and  a  very  severe 
erythema  may  be  caused  if  the  cure  be  in  any  way  pushed. 
Caution  is  needed  with  cardiac  patients,  as  syncopic  attacks 
may  come  on,  and  with  insomniacs  care  must  be  specially 
taken  to  keep  the  head  cool  with  damp  coverings. 

Electric  Light  as  compared  with  Sunlight. 

Electric  light  possesses  almost  identical  properties  with 
those  of  the  sun's  rays,  whether  we  are  referring  to  the  arc 
or  incandescent  lamp.  In  the  former  the  luminous  rays 
predominate,  and  in  the  latter  heat  rays.  Siemens  arrives 
at  the  following  conclusions  as  regards  the  physiological 
effect  of  the  electric  light: 

1.  Electric  light  has  the  effect  of  producing  chlorophyll 
in  the  leaves  of  plants,  promoting  growth,  and  favouring 
protoplasmic  activity. 

2.  The  action  of  artificial  light  is  identical  with  that  of 
daylight. 

3.  Under  the  influence  of  electric  light  plants  have  been 
observed  to  sustain  increased  stove  heat  without  collapsing, 
showing  the  value  of  light  as  a  vital  stimulant. 

4.  It  has  been  found  that  bacteria  are  killed  in  a  few 
minutes  by  exposure  to  the  concentrated  rays  of  a  6,000 
candle-power  lamp. 

The  Electric  Light  Bath. 

This  consists  of  a  cabinet,  vertical  or  horizontal,  in  the 
sides  of  which  are  fixed  from  thirty-five  to  fifty  electric 
light  bulbs,  some  white  and  some  of  blue  glass,  to  cut  out 
the  irritating  actinic  rays.  The  inside  may  be  simply  white 
enamelled,  but  is  preferably  covered  with  opalite  glass  or 
mirrors,  which  latter  enhance  the  light  effect.  If  vertical, 
the  patient  sits  erect  on  a  stool  with  his  head  outside,  the 
naked  surface  of  the  body  being  exposed  to  the  action  of 


40 


MANUAL  OF  PHYSIO-THERAPEUTICS 


the  lamps  for  a  period  of  from  ten  minutes  up  to  twenty-five 
or  thirty.  The  size  most  convenient  is  about  five  feet  in 
height  and  four  feet  wide.  The  lamps  are  32  candle-power, 
and  are  set  in  vertical  rows,  seven  in  a  row.  The  stool 
should  be  of  the  music  stool  adjustable  type,  as  some  patients 
may  find  the  bath  too  high  to  adjust  their  head  outside 
comfortably  with  a  standard  stool.  In  any  case,  many 
patients  find  the  vertical  bath  keeps  them  in  a  somewhat 


• 


FIG.  14. — THE  ELECTRIC  LIGHT  BATH  (RECUMBENT). 

constrained  position,  and  of  course  in  weakly  subjects  the 
tendency  to  faint  is  greater.  Thus  there  is  much  to  be  said 
for  the  horizontal  type  of  bath  as  shown  in  Fig.  14 

Precautions. — The  feet  of  the  patient  should  be  warm  and 
the  head  kept  cool.  A  foot  bath  may  be  used  for  the  first 
object,  and  the  head  be  covered  with  a  damp  towel  or  even 
Leiter's  tubes  for  the  latter. 

The  time  spent  in  the  bath  should  rarely  exceed  fifteen 
minutes.  Free  diaphoresis  occurs  usually  after  this,  and  the 
patient  does  better  usually  if  transferred  to  a  hot- water  bath 
or  given  a  Vichy  douche.  The  thermometer  in  the  light 


PHOTOTHERAPY 


41 


bath  should  register  as  a  mean  65°  C.,  but  the  temperature 
may  vary  from  32°  to  94°  C.  The  heat  is  conveyed  to  the 
patient  by  radiation,  not  by  conduction,  so  that  the  tem- 
perature of  the  air  immediately  around  the  patient  is  of 
little  moment.  The  less  moisture  there  is  in  the  air  the 


FIG.  15 — THE  ELECTRIC  LIGHT  BATH  (UPRIGHT). 

higher  will  be  the  temperature  tolerable  to  the  patient.  It 
is  therefore  essential  that,  whatever  the  type,  the  ventilation 
of  the  bath  be  good. 

While  the  number  of  lamps  in  the  bath  is  actually  fixed, 
the  number  of  lamps  actually  alight  can  be  readily  varied 
by  the  use  of  the  switches,  there  usually  being  one  for  each 
row  of  lamps. 


42 


MANUAL  OF  PHYSIO-THERAPEUTICS 


Some  baths  have  an  arrangement  whereby  the  arc  lamp 
can  be  turned  on  through  an  aperture  from  outside  to  any 
part  it  is  specially  desired  to  treat. 

After  the  bath  is  over,  the  patient  is  either  transferred 
to  a  hot  bath  of  plain  water,  to  a  Vichy  douche,  as  mentioned 


Applied  to  Base  of  Thorax. 


Applied  to  Lumbar  Region. 
Tin.  16. — LOCAL  ELECTRIC  LIGHT  BATH. 

above,  or  is  shampooed  and  carefully  sprayed  down  and  the 
wrapped  in  a  warm  bath  sheet  and  allowed  to  rest. 

1 .  Physiological  Action. — This  bath  is  most  valuable  as 
a  heating  agent.  By  prolonged  application  the  skin  of  the 
patient  is  reddened,  the  superficial  vessels  dilated,  just  as  in 


PHOTOTHERAPY 


43 


Applied  to  Knee. 


Applied  to  Sciatic  Eegion. 


Applied  to  Eight  Shoulder. 
FIG.  16A. — LOCAL  ELECTRIC  LIGHT  BATH. 


44          MANUAL  OF  PHYSIO-THERAPEUTICS 

an  ordinary  vapour  bath,  the  effect  being  kept  up  for  a 
considerable  time.  The  bath  is  essentially  an  eliminant  in 
effect,  and  produces  free  perspiration  more  rapidly  than  any 
other  known  procedure. 

2.  The  sweat  appears  within  five  minutes  of  the  patient 
entering  the  bath,  irrespective  of  the  actual  air  temperature 
in  the  cabinet.     The  time  required  to  induce  diaphoresis  in 
an  ordinary  Turkish  bath  is  very  much  longer ;  indeed,  some 
persons  never  perspire  at  all. 

3.  The  body  temperature   rises   rapidly  in  the  electric 
light  bath — 4°  to  5°  F.  in  twenty  minutes. 

4.  The  increased  elimination  of  C0»  is  very  marked,  and 
evidences  the  active  oxidation  and  tissue  changes  induced 
by  this  procedure. 

Kellogg  estimates  the  increase  as  nearly  50  per  cent. 
Comparatively,  in  a  Russian  or  Turkish  bath  the  increase 
is  only  found  to  be  10  to  11  per  cent.  The  respiration  of  the 
patient,  while  considerably  quickened,  is  free  and  unem- 
barrassed. None  of  the  oppression  and  distress  met  with 
in  the  Turkish  or  Russian  bath  is  induced. 

5.  The  blood-pressure,  after  a  primary  rise,  is  lowered. 
The  red  cells  are  increased  by  about   15  per  cent.     The 
pulse-rate  is  somewhat  quickened. 

THERAPEUTIC  EFFECTS 

1.  Revulsive  Effect. — By  the  rapidly  induced  and  pro- 
longed dilatation  of  the  cutaneous  bloodvessels  the  blood 
is  diverted  to  the  surface  of  the  body,  and  passive  venous 
congestion  converted  into  an  active  arterial  hyperaemia. 
The  longer  the  bath  is  continued,  the  more  intense  does 
this  effect  become. 

2.  Sudorific  Effect. — Perspiration  is  induced  more  quickly 
and  vigorously  than  by  any  other  known  agent,  with  a 
minimum  of  inconvenience  and  discomfort  to  the  patient. 
Copious    water-drinking   during   the   bath   encourages   the 
perspiration    and   keeps    the    blood-volume    constant.     As 
above  mentioned,  the  head  should  be  wrapped  in  cold  cloths, 
especially  if  the  bath  is  prolonged. 

3.  For  promoting  the  absorption  of  morbid  exudates,  such 


PHOTOTHERAPY  45 

as  pleural  effusion,  ascites,  or  joint  effusions,  the  electric 
light  bath  is  admirably  adapted. 

4.  Tonic  Effect. — A  brief  application— five  to  eight 
minutes — has  a  bracing  and  tonic  effect.  The  after- applica- 
tion of  a  warm  to  cold  spray  and  a  dry  rub  enhances  the 
stimulating  effect. 

THERAPEUTIC  INDICATIONS. 

The  condition  of  disordered  metabolism  which  goes  under 
the  name  of  "  uric  acid  diathesis  "  is  much  benefited  by  a 
series  of  electric  light  baths. 

By  the  increased  oxidation  and  improA7ed  metabolism 
the  nitrogenous  by-products  and  toxic  substances  are 
gradually  eliminated,  with  proportional  benefit  to  the 
patient.  The  application  should  be  made  two  or  three 
times  weekly,  and  should  be  combined  with  suitable  diet, 
free  water-drinking,  and  plenty  of  exercise.  Allied 
conditions  which  similarly  benefit  are  rheumatism,  gout, 
diabetes,  and  some  forms  of  neurasthenia. 

Fat  glycosurics  are  most  benefited.     The  skin  is  rendered 

o   »/ 

more  active  as  an  organ  of  elimination,  and  the  free  dia- 
phoresis and  increased  oxidation  reduces  the  amount  of 
sugar  in  the  urine.  The  blood  is  rendered  more  alkaline, 
and  the  tendency  to  "  acid  intoxication,"  so  well  known  in 
glycosuria,  correspondingly  diminished. 

Obesity. — In  the  treatment  of  this  condition  the  electric 
light  is  a  most  potent  and  valuable  agent.  As  stated  above, 
the  increase  of  tissue  consumption  during  the  bath  amounts 
to  from  45  to  50  per  cent.,  and  as  three-fourths  of  the  energy 
of  the  body  is  consumed  in  heat  production,  the  value  of 
this  is  very  obvious.  An  increase  such  as  this,  kept  up  for 
from  thirty  to  forty  minutes  several  times  every  week, 
naturally  results  in  a  considerable  weight  reduction.  The 
heat  elimination  and  tissue  consumption  is  greatly  increased 
when  the  temperature  of  the  air  surrounding  the  patient  is 
lower  than  the  body  temperature. 

Neuralgia,  including  sciatica,  myalgia,  and  the  various 
vague  pains  associated  with  auto-intoxication,  are  all 
benefited  markedly.  Conditions  such  as  plumbism  and 


46          MANUAL  OF  PHYSIO-THERAPEUTICS 

arsenical  poisoning  and  neuritis  are  improved,  a  daily 
application  being  sometimes  necessary.  In  a  minor  degree 
anaemic  conditions  are  benefited,  and  the  recuperative  powers 
of  the  body  helped  to  re-establish  the  normal  haemopoietic 
processes. 

Renal  Disease. — Few  measures  afford  such  marked  relief  to 
acute  and  subacute  renal  disease  as  the  electric  light  bath. 
Prompt  relief  is  afforded  to  the  inflamed  organs  by  so  large 
a  portion  of  the  blood  being  diverted  to  the  skin.  The 
application  should  be  rather  longer  than  usual,  the  patient 
being  refreshed  from  time  to  time  by  a  rub  with  a  friction 
glove  wrung  out  of  hot  water.  The  usual  precautions  as 
regards  keeping  the  head  cool  and  the  feet  warm  are  especially 
necessary,  and  great  care  is  further  requisite  to  avoid  a  chill, 
which  would  more  than  counteract  any  good  effects  of  the 
bath.  In  acute  cases  the  bath  may  be  repeated  several 
times  in  the  twenty-four  hours,  and  a  condition  of  con- 
tinuous diaphoresis  is  maintained. 

In  chronic  granular  kidney  special  care  is  called  for  in 
prescribing  these  baths,  and  in  administering  them  if  the 
risk  be  taken;  there  is  always  a  danger  of  apoplexy.  In 
cardiac  hypertrophy  and  dropsy  special  care  is  also  needed, 
and  high  temperatures  and  long  exposure  must  be  avoided. 
The  bath  should  be  brief  in  duration,  and  an  ice-bag  or 
cooling  application  be  placed  on  the  patient's  head. 

There  are  a  variety  of  other  conditions  which  may  be 
more  or  less  helpful  which  it  is  hardly  needful  to  enter  into 
here.  In  conclusion,  however,  one  may  say  that  the  thera- 
peutic value  of  the  electric  light  bath  and  its  great  advance 
over  the  Turkish  can  hardly  be  overstated.  It  is,  in  the 
first  place,  a  preventive  of  disease,  chills,  and  auto-intoxica- 
tion par  excellence  in  the  average  healthy  person  and  as  an 
eliminant  has  no  rival,  bringing  into  play  in  full  the  largest 
gland  in  the  body — the  skin,  by  means  of  which  such  a  very 
large  proportion  of  waste  products  is  normally  eliminated. 


PHOTOTHERAPY  47 


The  Leucodescent  Lamp. 

This  is  a  2,000  candle-power  therapeutic  lamp  swung  on 
pulleys  so  as  to  be  easily  adjusted  to  any  part  of  the  patient. 
One  of  us  has  used  a  lamp  of  this  type  for  about  ten  years, 
and  with  the  greatest  satisfaction.  Humphris  also  speaks 
very  highly  of  it. 

The  globe  carrying  the  incandescent  filament  is  surrounded 
by  a  brightly  polished  metal  hood,  the  whole  being  swung 
on  a  sort  of  iron  trolley  with  a  counter-weight,  rendering 
adjustment  very  simple. 

The  method  of  applying  the  lamp  is  to  swing  it  slowly 
backwards  and  forwards  over  the  affected  part  for  about 
twenty  minutes  to  half  an  hour.  The  distance  it  is  kept  from 
the  skin  must  depend  a  great  deal  on  the  tolerance  of  the 
patient,  which,  of  course,  varies  greatly  with  the  individual. 
The  skin  must  be  bare  for  direct  application,  no  fabric  of 
any  kind  intervening.  The  application  is  neither  painful 
nor  unpleasant  if  the  heat  be  controlled  by  the  swinging 
movement  above  mentioned.  The  duration  of  the  treat- 
ment will  vary  with  the  nature  of  the  case,  as  will  the  fre- 
quency. In  acute  cases  short  treatments  frequently  re- 
peated are  often  most  efficacious.  If  the  pain  is  relieved  and 
checked  by  daily  application,  then  these  should  be  employed 
until  it  disappears.  A  sharp  attack  of  lumbago  will  close 
up  in  a  few  days,  while  a  long-standing  neuritis  or  sciatica 
may  take  weeks. 

The  modus  operandi  is,  of  course,  by  causing  passive 
congestion  initially  and  preparing  the  way  for  more  effica- 
cious massage.  The  sweat  glands  are  stimulated  and  the 
capillaries  dilated;  normal  circulation  is  promoted,  and 
venous  stasis  removed.  It  is  even  suggested  that  the  light 
has  a  bactericidal  action  on  superficial  germs. 

Accordingly,  pain  is  relieved  and  the  functional  activity 
of  the  skin  and  deeper  glands  restored.  Humphris  goes  so 
far  as  to  say  if  pain  is  not  relieved  by  this  procedure  the 
services  of  a  surgeon  will  be  required. 

Of  the  conditions  which  are  greatly  benefited  and  cured, 
rheumatic  affections  of  muscles,  joints,  and  nerves  come 


48 


MANUAL  OF  PHYSIO-THERAPEUTICS 


first.  Humphris  has  used  the  lamp  in  painful  digestive 
conditions,  however,  with  good  result,  and  also  in  neuras- 
thenia and  insomnia.  Boils  and  carbuncles  are  relieved  and 
the  cure  accelerated.  Pleurodynia  is  a  typical  condition  to 
which  relief  is  afforded,  and  "  stiff  neck." 


FIG.  17. — THE  LEUCODESCENT  LAMP. 

In  skin  affections,  acne,  tinea  sycosis,  some  forms  of 
eczema,  and  psoriasis,  appear  to  be  benefited  if  treated  with 
care  and  discretion. 

Taking  it  all  round,  there  is  no  more  simple  and  effective 
piece  of  apparatus  in  the  domain  of  physio-therapy  with 
such  a  wide  field  of  usefulness  in  relieving  painful  affections. 


SECTION   II 
HYDROTHERAPY 

CHAPTER  I 
GENERAL  PRINCIPLES 

THERMOTHERAPY  consists  in  the  application  of  heat  as  a 
therapeutic  agent  at  all  temperatures  and  irrespective  of 
the  media  by  means  of  which  the  heat  is  conveyed.  Thermal 
applications  include  hot  and  cold  water  baths,  and  air, 
vapour,  electric  light,  and  sunlight  baths. 

One  of  the  commonest  means  employed  for  conveying 
thermic  stimuli  to  the  body  is  water,  and  in  describing  the 
temperature  of  such  applications  or  procedures  (see  also 
chart,  Fig.  2),  the  following  standard  is  customary : 

Temperatures. 
Very  liot  applications     .  .  .  .  . .          over  40°  C. 

Hot  applications  .  .  . .  37°  to  40°  C. 

Warm  . .  34°  to  37°  C, 


Tepid 

Cool 

Cold 

Very  cold 


27°  to  33-5°  C. 

18°  to  27°  C. 

12-5°  to  18Q  C. 

0°  to  12-5°  C. 


Hydrotherapy  consists  in  the  systematic  application  of 
water  at  various  temperatures  and  in  varying  form  to 
the  surface  of  the  body  for  therapeutic  purposes.  Water 
may  produce  its  effects  by  (1)  its  temperature,  (2)  its 
volume,  (3)  mechanically,  (4)  chemically. 

Water  possesses  such  physical  properties  as  render  it 
an  excellent  medium  for  conveying  temperature  impressions. 
It  has  a  remarkable  eapacity  for  heat  absorption  without 
material  rise  in  temperature,  and  gives  off  heat  without 
much  temperature  reduction.  It  takes  a  much  larger  amount 

49  4 


50          MANUAL  OF  PHYSIO-THERAPEUTICS 

of  heat  to  raise  the  temperature  of  a  pound  weight  of  water 
1°  C.  than  an  equal  bulk  of  oil  or  metal.  It  is  for  this 
reason  that  water  is  used  for  "  thermophores "  and  the 
domestic  hot-water  bottle,  and  on  this  fact  depends  the  even 
temperature  of  insular  climates.  The  heat-conducting 
power  of  water,  as  compared  with  that  of  air,  is  as  27  to  1, 
and  much  more  powerful  thermal  impressions  are  made  on 
the  skin  by  water  than  air,  the  temperature  being  the  same. 

As  a  result  of  different  temperatures  water  undergoes 
peculiar  changes,  solidifying  at  0°  C.  and  becoming  gaseous 
at  100°  C.,  the  volume  increasing  1,700  times.  The  heat 
absorbed  and  evolved  respectively  in  these  changes  in  rts 
molecular  constitution  is  utilized  in  various  ways  in  hydro- 
therapy. 

The  temperature  of  water,  more  than  that  of  any  other 
medium,  is  readily  adapted  to  individual  cases  and  with 
great  precision.  The  range  of  safety  in  temperature  is 
from  1°  C.  to  48-5°  C. ;  long-continued  application  of  water 
above  or  below  this  temperature  may  produce  tissue  necrosis. 
Water  is  thus  said  to  possess  a  high  degree  of  thermic  flexi- 
bility (Baruch). 

The  fluidity  of  water  allows  of  its  local  and  general  effects 
being  regulated  with  the  utmost  nicety  and  precision,  and 
the  size,  form,  and  character  of  its  application — in  the  form 
of  a  stream  or  douche — can  be  instantly  changed.  Thera- 
peutic effects  of  great  value  are  brought  about  by  the 
mechanical  action  of  water  emitted  under  various  degrees 
of  pressure,  varying  from  the  mildest  stimulation  to  intense 
irritation.  Cold  and  heat  and  gradations  of  temperature 
act  as  nerve  stimuli.  The  result  of  bringing  water,  higher 
or  lower  in  temperature,  into  contact  with  the  body  is  a 
modification  of  the  quality  of  innervation  at  point  of 
contact.  The  sensory  peripheral  nerve  terminations  are 
brought  into  a  state  of  increased,  diminished,  or  altered 
excitability. 

The  result  depends  on  the  degree  of  difference  in  tempera- 
ture between  the  skin  and  the  water  or  medium  em- 
ployed, on  the  suddenness  of  application,  the  duration  of  its 
action,  the  extent  of  body  exposed,  the  variable  sensibility 
of  the  subject  treated,  and  the  simultaneous  mechanical  and 


GENERAL  PRINCIPLES  51 

chemical  stimulation.  The  effects  induced  are  due  to  various 
continuations  of  these  factors,  and  may  be  purely  local  or 
reflex.  Secondary  effects  also  result  from  the  supply  or 
abstraction  of  heat.  Powerful  therapeutic  actions  may  be 
brought  about  by  the  excitation  of  peripheral  stimuli  or  by 
their  inhibition.  Digestion  an.d  metabolism  may  by  this 
means  be  strongly  stimulated  or  depressed ;  the  vigour  and 
frequency  of  the  cardiac  systole  may  be  likewise  influenced, 
and  the  general  distribution  of  the  blood  and  local  and 
general  nutrition  affected.  Widely  different  disorders  of 
metabolism — various  secretions  and  excretions — undergo 
alteration. 

Local  Cooling  and   Heating. — The   effects   of  the  local 
application  of  cold  and  heat  are  as  follows : 

1.  Cooling  or  heating  of  the  surface  in  contact  with  the 
medium  until  the  temperature  is  almost  identical.     The 
surface  temperature  is  always  slightly  higher  or  lower  so 
long  as  the  application  of  cold  or  heat  respectively  be  not 
excessive  and  harmful. 

2.  Local   cooling   or   heating   do   not   modify   the   body 
temperature  unless  the  area  exposed  comprises  a  quarter 
of  the  body  surface. 

3.  Any  region  of  the  body  can  be  warmed  or  cooled  to 
any  desired  temperature  by  the  supply  or  withdrawal  of 
heat  for  a  sufficient  period  of  time  and  intensity  of  degree. 

4.  Heating    and    cooling    take    place   more    rapidly   the 
higher  and  the  lower  the  surrounding  temperature  after 
the  thermic  application. 

5.  The  promptitude  and  degree  of  reaction  succeeding 
heat  abstraction  and  heat  supply  are  directly  proportional 
to  the  intensity,  and  inversely  proportional  to  the  duration 
of  the  application. 

6.  Active    and   passive    movements    of   the   part    under 
treatment  bring  about  more  rapid  restoration  of  heat  or  cold 
than  occurs  when  it  remains  at  rest. 

7.  Local  warming  is  followed  by  cooling  of  the  surface, 
and  local  cooling  by  warming,  showing  the  alteration  of 
heat  distribution. 

8.  Metabolism  is  retarded  in  cooled  and  accelerated  in 
warmed  tissues. 


52          MANUAL  OF  PHYSIO-THERAPEUTICS 

General  Heating  and  Cooling. — There  are  several 
automatic  protective  agencies  against  the  general  reduction 
of  body  temperature.  Chief  among  these  are : 

1.  Reduction  of  the  temperature  of  the  surface  of  the 
body,  diminishing  the  heat  tension  between  skin  and  cooling 
medium  employed,  and  so  diminishing  heat  loss. 

2.  Diminution  of  circulation  in  the  skin,  and  resulting  col- 
lateral hypersemia  in  muscular  layer  of  the  entire  body.     So, 
though  the  skin  be  cooled,  the  muscular  tissue,  supplied  freely 
with  blood,  prevents  too  extensive  chilling  of  internal  organs. 

3.  The  rise  in  temperature  of  muscles  on  the  withdrawal 
of  heat  is  induced  not  only  by  collateral  hypersemia,  but 
also  by  reflex  thermal  influences.     While  cold  causes  con- 
traction of  the  cutaneous  vessels,  it  induces  dilatation  of  the 
vessels  of  the  muscular  layer. 

4.  The  hypereemia  of  the  muscles  tends  to  increase  thermo- 
genesis  in  the  tissues. 

It  will  thus  be  seen  that  the  muscular  layer  of  the  body, 
by  both  storing  and  generating  heat,  is  a  most  powerful 
agent  in  protecting  the  internal  organs  from  excessive  cold, 
and  is  in  turn  protected  by  the  skin  covering  it. 

Physiological  Reaction  after  Hydrotherapeutic  Proce- 
dures.— The  intensity  of  the  reaction  occurring  after  any 
bath  or  thermal  application,  while  partially  dependent  on 
the  character  of  the  procedure,  varies  greatly  with  the 
individual.  To  produce  a  proper  degree  of  reaction  after 
all  forms  of  treatment  is  most  important,  and  depends  on 
the  suitable  adjustment  of  the  stimulation  to  the  individual, 
for  the  rapidity  with  which  heat  is  restored  after  heat 
abstraction  varies  immensely  in  different  cases.  It  is 
especially  important  in  treating  any  case  that  the  elevation 
of  temperature  of  reaction  following  heat  abstraction  be 
carefully  controlled.  It  is  often  requisite  to  diminish  or 
increase  its  rapidity  or  degree.  The  proper  restoration  of 
heat  depends  on : 

1.  The  degree  of  heat  abstraction,  ceteris  paribus  ;  the 
greater   the   abstraction,    the    more   extensive   the    rise    of 
temperature  in  reaction. 

2.  The  time  taken  in  the  process  of  heat   abstraction. 
Gradual  heat  loss  leads  to  a  gradual  reactive  process. 


GENERAL  PRINCIPLES  53 

3.  The  body  temperature  prior  to  the  heat  abstraction. 
If  previous  heating  be  applied,  a  better  and  quicker  reaction 
is  obtained. 

4.  The    application    of    friction    and    other    forms    of 
mechanical  stimulation  hastening  the  reaction. 

5.  Exercise   subsequent  to   heat  abstraction  quickening 
the  outset  of  reaction,  as  does  also  the  internal  administra- 
tion of  stimulants  such  as  alcohol  and  hot  coffee. 

6.  The  heat  abstraction  not  being  carried  to  excess,  for 
in  that  case  the  reaction  may  be  much  delayed  or  incom- 
plete. 

Ba  metis  Test  for  Reactive  Capacity. — The  response  of 
the  cutaneous  circulation  to  mechanical  stimuli  is  an  index 
to  the  probable  reactive  capacity  of  the  patient.  "  Passing 
the  back  of  the  nail  of  the  index  finger  rapidly  but  gently 
across  the  surface  of  the  abdomen,  and  increasing  the 
pressure  of  the  nail  with  a  parallel  second  stroke,  induces 
more  or  less  reddening  of  the  irritated  skin.  The  rapidity 
with  which  the  red  line  develops  after  the  nail  is  removed, 
and  the  pressure  required  to  produce  it,  give  a  fairly  correct 
test,  to  the  trained  observer,  of  the  patient's  reactive 
capacity." 

If  good  effects  are  to  follow  the  application  of  hydro- 
therapeutic  processes,  a  perfect  and  complete  reaction  is 
essential.  We  may  desire  to  modify  its  character  in  various 
ways  to  induce  a  slow  or  quick  reaction,  but  an  incomplete 
reaction  is  never  beneficial  or  desirable.  It  is  characterized 
by  lassitude,  pallor,  poor  pulse,  a  chilly  feeling,  "  cold 
water  down  the  back,"  shivering,  etc.  If  repeatedly 
occurring,  it  will  seriously  disturb  the  patient's  health. 

The  beneficial  effects  of  the  hydrotherapeutic  procedures 
only  resulting  when  a  good  reaction  is  obtained,  thus  in- 
tensifying the  natural  defensive  powers  of  the  organism,  it 
follows  that  in  enfeebled  individuals  it  is  necessary  to  take 
all  precautions  to  bring  about  a  complete  reaction,  and 
so  insure  the  maximum  amount  of  good  from  physical 
remedial  measures. 

The  automatic  protective  measures  against  heat  are : 

1.  Dilatation  of  the  cutaneous  vessels  and  acceleration 
of  the  circulation  through  the  skin  and  subcutaneous  tissues. 


54          MANUAL  OF  PHYSIO-THERAPEUTICS 

By  the  application  of  heat  to  the  skin  the  cutaneous  vessels 
are  dilated,  the  circulation  is  accelerated,  the  secretion  of 
the  skin  is  increased,  and  sweat  is  evaporated  from  the 
surface.  Heat  loss  is  thus  effected,  and  the  blood  circulating 
in  the  skin  cooled.  It  returns  to  the  internal  organs,  and 
thus  prevents  their  becoming  overheated. 

2.  If  heat  application  be  prolonged,  a  large  amount  of 
blood  will  be  retained  in  the  skin  in  consequence  of  the  loss 
of  tone  in  the  skin  vessels;  the  cutaneous  circulation  is 
slower,  and  the  overheated  blood  prevented  from  returning 
to  the  internal  organs,  to  their  hurt. 

3.  The  blood  being  diverted  to  the  skin,  a  diminished 
amount  of  blood  will  remain  in  the  internal  organs,  and 
their  activity  be  accordingly  renewed.     Excessively  rapid 
penetration  of  heat  to  internal  organs  is  thus  prevented, 
and  unduly  rapid  elevation  of  body  temperature  checked. 

Heat  Regulation,  or  Thermotaxis. — As  a  result  of  the 
stimulating  effects  of  cold,  there  first  occurs  contraction  of 
the  skin  and  its  vessels,  which  by  restricting  heat  loss  leads 
to  perfect  compensation  if  the  abstraction  of  heat  be  slight, 
partial  compensation  if  heat  loss  be  marked.  In  the  latter 
case  the  body  temperature  will  continue  to  decline  in  greater 
or  less  degree ;  in  the  former  it  will  remain  constant.  Altera- 
tions in  thermogenesis  depend  on  tonic  and  clonic  muscular 
contractions  (i.e.,  muscular  tension  or  tremulous  movement) 
that  occur  involuntarily  (i.e.,  shivering)  as  the  result  of 
ssvere  cold,  just  as  they  do  in  consequence  of  other  sense 
irritations.  These  are  less  important  as  a  thermotactic 
measure  than  the  contraction  of  skin,  for  they  cannot 
prevent  reduction  of  body  temperature. 

Physiological  Effect  of  Heat. — Primarily,  heat  acts  as  a 
stimulant  or  excitant.  The  activity  of  cellular  protoplasm 
is  increased,  whether  the  cells  be  leucocytes,  lymphocytes, 
or  nerve  or  muscle  cells.  Such  increased  activity  is  but 
temporary,  however,  and  secondary  depression  follows  as 
the  inevitable  reaction.  This  reaction  is  due  to  increased 
heat  production  and  lower  blood-pressure.  When  cold 
is  applied  to  the  body — in  moderate  degree — heat  produc- 
tion is  increased,  cardiac  contractions  are  stronger,  and 
blood-pressure  is  raised.  Heat  is  therefore  primarily  an 


GENERAL  PRINCIPLES  55 

excitant  and  secondarily  a  depressant,  while  cold  is  the 
reverse. 

The  effect  following  the  application  of  heat  depends  on 
the  form,  duration,  and  temperature  of  the  application, 
but  also  largely  on  the  condition  of  the  patient.  High 
temperatures  are  first  excitant  and  then  depressant,  the 
degree  of  depression  being  in  proportion  to  the  length  of 
the  application.  After  a  brief  one  the  depressing  effect  may 
be  insignificant.  Applications  of  moderate  temperature  are 
followed  by  a  less  degree  of  excitement  and  depression. 

The  abstraction  of  heat  causes  increase  in  metabolic 
activity  only  if  voluntary  or  involuntary  muscular  contrac- 
tions occur  at  the  same  time.  So  long,  therefore,  as  the 
temperature  in  the  muscle  layer  is  increased,  and  remains 
increased  in  spite  of  heat  loss,  the  stimulation  induced 
thereby  will  lead  to  increase  of  heat  production,  and 
this  constitutes  an  important  factor  in  heat  regulation. 
Further,  exercise  so  strengthens  the  heat-regulating  powers 
of  the  body  that  they  are  rendered  capable  of  compensating 
most  completely  the  supply  and  loss  of  heat. 

The  functions  of  the  skin  control  heat  loss,  voluntary 
or  involuntary;  muscular  contraction  and  change,  in  turn, 
control  thermogenesis.  And  each  of  these  can  be  increased 
or  lessened  at  will  by  thermic  or  mechanical  influences. 


General  Effect  of  Hydrotherapeutic  Applications. 

General  Effect  on  Metabolism. — The  general  application 
of  heat,  after  raising  the  body  temperature,  causes  increased 
oxidation  and  excretion  of  C02.  The  blood  is  rendered 
more  resistant  to  morbid  influences  by  the  increase  of 
alexins,  and  on  this  basis  rests  the  belief  that  the  elevation 
of  temperature  in  the  exanthemata  and  various  inflamma- 
tory disorders  is  merely  a  protective  measure,  and  is,  indeed, 
remedial.  The  application  of  a  fomentation  or  poultice 
to  any  inflamed  region  hastens  repair  by  inducing  increased 
flow  of  blood  and  causing  a  local  leucocytosis.  Cold 
increases  oxidation  and  elimination  of  CO.,,  and,  the 
body  temperature  remaining  constant,  heat  produces  a 


56          MANUAL  OF  PHYSIO-THERAPEUTICS 

reverse   effect.     The   greater  the  thermic  nerve  stimulus, 
the  greater  will  be  the  reflex  increase  in  metabolism. 

Systematic  abstraction  of  heat  causes  secondarily  an 
increase  in  body  temperature,  leading  to  the  modification 
of  the  metabolic  processes  such  as  occurs  in  all  febrile 
conditions.  The  reduction  of  the  body  temperature  of 
a  normal  person  by  cold  application  will  lead  to  a  reactive 
process  which  tends  to  take  the  temperature  back  to  the 
normal,  or  even  above  it.  Repetition  of  such  application 
produces  in  normal  healthy  people  an  increased  reactive 
capacity,  and  a  tendency  to  rise  rapidly  to  the  normal 
temperature. 

Action  on  the  Skin. — Contraction  of  the  smooth  muscle 
fibres  of  the  skin  is  caused  by  brief  application  of  intense 
heat,  and  "  goose  flesh  "  results.  By  prolonged  application 
the  sweat  glands  are  excited,  and  the  amount  of  perspira- 
tion may  be  increased  twenty-fold.  Marked  hyperaesthesia 
is  caused  by  temperatures  of  over  50°  C.  Primary  pallor 
of  the  skin  quickly  changes  to  redness  as  the  cutaneous 
vessels  dilate,  and  with  the  reaction  later  pallor  returns. 

Action  on  the  Muscles  and  Muscular  Tissue. — Increase 
and  diminution  in  tension  of  all  muscle  tissues  are  induced 
by  the  application  of  thermic  or  mechanical  stimuli,  botli 
voluntary  and  involuntary  muscles  being  affected.  The 
application  of  cold,  and  of  massage  or  friction,  increases 
the  tone  in  all  voluntary  muscle  tissue.  The  muscular 
tissue  may  simply  be  increased,  or  clonic  or  toxic  spasm 
induced.  There  is  increased  production  of  heat,  and  of 
capacity  for  withstanding  fatigue.  Temporary  application 
of  heat  will  produce  similar  effects,  but  if  prolonged  this 
leads  to  fatigue  and  weakness,  and  lessens  heat  production. 

Muscular  energy  is  increased  by  brief  hot  appliances; 
relaxation  results  from  longer  applications.  Practically 
we  utilize  this  latter  action  in  relieving  cramp  of  a  muscle, 
or  of  the  stomach  or  intestine. 

Action  on  the  Nervous  System.—  Reflex  excitement  of 
the  nerve  centres  is  induced  by  brief  applications  of  heat; 
exhaustion  follows  if  they  are  prolonged.  By  warm  or 
hot  applications  nerve  sensibility  is  subdued,  and  a  com- 
fortable sensation  induced,  without  depression  or  lassitude. 


GENERAL  PRINCIPLES  57 

Effect  on  Blood  Constitution. — The  application  of  cold 
to  the  body  surface  usually  induces  a  varying  degree  of 
leucocytosis  and  increase  of  erythrocytes,  while  the  colour 
index  also  rises.  The  leucocytosis  may  amount  to  18,000  or 
20,000;  the  erythrocytes  may  increase  by  1  or  l|  millions, 
and  the  hemoglobin  often  by  12  or  15  per  cent.  These 
effects  are  usually  obtained  within  an  hour.  The  increase 
is  only  temporary,  however,  being  comparable  to  the 
physiological  increase  in  haemoglobin  occurring  after  an 
ordinary  meal.  Active  muscular  exercise  has  a  very  similar 
effect.  If  a  good  reaction  be  not  obtained  these  effects  are 
not  produced,  but,  on  the  contrary,  there  may  be  a  diminu- 
tion in  the  number  both  of  erythrocytes  and  leucocytes. 

Warm  fomentations  and  poultices  cause  a  local  increase 
in  the  leucocytes  and  a  diminution  in  red  cells,  while  warm 
sitz  baths  cause  a  general  reduction  in  both  types  of  cells 
as  well  as  in  haemoglobin  percentage. 

Winternitz  considers  there  is  a  fallacy  in  this  increased 
blood-count  above  spoken  of.  He  points  out  the  marked 
difference  in  composition  of  blood — as  regards  percentage 
of  cellular  elements — in  a  drop  taken  from  the  finger-tip  and 
one  taken  from  the  abdominal  wall.  He  further  attributes 
the  temporary  leucocytosis,  etc.,  to  brisker  circulatory 
conditions  sweeping  out  into  the  general  blood-stream 
leucocytes  and  red  cells  which  were  stagnating  in  various 
internal  organs.  He  points  out  that,  though  the  increase 
is  only  temporary  in  large  degree,  still  gaseous  interchange 
is  encouraged  here,  oxygen  being  taken  up  and  C02  thrown 
out  in  the  respiration,  and  nutritive  processes  being  height- 
ened ;  while  by  methodical  repetition  of  the  thermic  applica- 
tions which  lead  to  the  temporary  effect  a  permanent  one 
is  attained. 

Action  on  the  Cardie-Vascular  System. — Application  of 
cold  at  first  quickens  the  cardiac  beats,  and  later  slows  but 
strengthens  them,  whilst  hot  applications  produce  the 
reverse  effects.  There  is  a  lengthening  of  the  diastole,  with 
improved  cardiac  nutrition.  Similarly,  as  regards  the 
peripheral  circulation,  there  is  a  primary  vaso-constriction 
and  then  vaso-dilatation.  The  blood  pressure  itself  rises 
after  the  application  of  cold  as  much  as  30  mm.  of  Hg  in 


58          MANUAL  OF  PHYSIO-THERAPEUTICS 

many  cases,  and  is  lowered  to  a  somewhat  similar  extent 
after  application  of  heat.  In  both  cases  dilatation  of 
the  vessels  occurs,  but  cold  is  a  vasomotor  stimulant. 


FIG.  18. — EFFECT  OF  COLD  APPLICATION  ON  THE  PULSE 
TRACING:  (a)  BEFORE;  (b)  AFTER. 

While  very  hot  applications  produce  a  degree  of  cardiac 
excitement,  the  major  effect  is  vascular  dilatation  and 
lowered  blood -pressure. 

Primary    contraction    and    secondary    relaxation    of    the 
bloodvessels  are  produced  by  heat,  this  passive  dilatation 


FIG.  19. — EFFECT  OF  HOT  APPLICATION  ON  THE  PULSE 
TRACING:  (a)  BEFORE;  (b)  AFTER. 

causing  reddening  of  the  skin  through  cutaneous  vessels. 
The  effects  of  local  applications  of  hot  compresses,  hot 
baths,  etc.,  depend  on  the  fact  that,  while  the  peripheral 


GENERAL  PRINCIPLES  59 

vessels  of  any  area  are  in  a  dilated,  hyperaemic  condition, 
those  of  the  central  or  remaining  portion  are  contracted, 
a  compensatory  anaemia  of  the  region,  be  it  internal  organ 
or  joint,  resulting. 

When  we  consider  that  the  cutaneous  vessels  are  capable 
of  containing  two-thirds  of  the  total  amount  of  blood,  we 
are  able  to  see  how  powerful  an  influence  is  exerted  on 
blood-pressure  and  internal  congestion  by  the  dilatation  of 
the  whole  or  any  part  of  the  cutaneous  "  heart."  The  red 
blood-cells  are  diminished  by  the  general  or  local  application 
of  heat,  while  a  leucocytosis  is  induced.  The  alkalinity  of 
the  blood  is  lowered  also.  The  volume  of  the  blood  is 
lessened  by  the  prolonged  application  of  heat,  owing  to  loss 
of  fluid  by  the  profuse  perspiration  thereby  induced. 

Blood-Pressure. — Primarily,  the  effect  of  every  hot  and 
cold  douche  is  to  cause  a  rise  in  blood-pressure  by  con- 
tracting the  skin  capillaries,  with  an  associated  slower  but 
more  vigorous  heart-heat. 

Water  at  35°  to  40°  C.  causes  an  initial  rise  and  then  a 
secondary  fall,  with  a  later  further  rise.  At  a  higher  tem- 
perature the  blood-pressure  rises  and  pulse-rate  quickens, 
the  temperature  remaining  high. 

If  the  bath  involves  rubbing  and  mechanical  manipula- 
tion, the  pressure  goes  up  more,  but  soon  falls  to  normal. 

If  the  water  is  gaseous,  as  it  is  at  Nauheim,  or  with  arti- 
ficially aerated  baths  at  temperatures  below  32°  C.,  there 
is  a  lowering  of  abnormal  blood-pressure;  with  warmer 
water,  a  marked  fall.  Care  is  thus  obviously  called  for  in 
dealing  with  patients  who  have  diseased  cardio-vascular 
systems  and  a  high  blood-pressure,  as  the  immediate  drop 
produced  may  be  so  marked  as  to  be  dangerous,  and  entirely 
upset  their  cardio-vascular  equilibrium.  Careful  use  of  the 
stethoscope  along  with  the  now  generally  employed  sphyg- 
momanometer  will  prevent  any  untoward  events  of  this 
kind,  generally  speaking. 

Action  on  Respiration. — Dry  heat  hinders  the  respiratory 
gaseous  exchange,  quickening  the  rate  of  respiration,  but 
rendering  it  less  efficient  and  deep.  The  rate  of  respiration 
is  increased  by>  a  general  hot  bath,  and  after  a  little  the 
respirations  are  deeper  in  character.  The  skin  is  rendered 


60          MANUAL  OF  PHYSIO -THERAPEUTICS 

active,  with  resultant  diaphoresis,  but,  in  addition,  much 
moisture  and  toxic  material  is  thrown  off  by  way  of  the 
lungs. 

The  body  temperature  is  raised  by  a  bath  over  37°  C.,  owing 
to  interference  with  heat  elimination.  The  amount  of 
the  rise  will  depend  on  the  temperature  and  duration  of 
the  bath  and  the  body-weight  of  the  patient.  A  bath  at 
37°  C.  for  half  an  hour,  the  patient  being  an  average  size 
male  adult,  will  cause  a  rise  of  only  2°  C.  to  3°  C.,  while  if 
the  temperature  be  38°  C.  the  rise  may  be  as  much  as  1-5° 
or  3°  C.  The  dilatation  of  the  skin  vessels  induced  by 
a  brief  hot  bath  will  often  cause  a  fall  of  temperature, 
owing  to  increased  heat  loss. 

Action  on  the  Internal  Organs. — It  is  a  notorious  fact 
that  the  application  of  a  cold  bath  in  an  abdominal  examina- 
tion induces  rigidity  of  the  abdominal  wall,  owing  to  increased 
tone  of  the  muscles ;  whilst  the  relaxing  effect  of  heat  is  fre- 
quently made  use  of  in  the  reducing  of  herniae  and  the  relief 
of  spasms,  colics,  etc.  If,  however,  cold  be  applied  to  the 
abdominal  muscles,  not  only  are  they  themselves  contracted, 
but  the  involuntary  muscular  tissue  of  the  stomach,  intestine, 
gall-bladder,  etc.,  also  contracts.  Relaxed  abdominal 
muscles  lead  to  diminished  intra-abdominal  tension,  portal 
engorgement,  and  congestion  of  the  viscera.  Gastric  dilata- 
tion, indigestion,  and  constipation  may  result,  with  conse- 
quent malaise  and  malnutrition. 

Blood  may  be  diverted  from  any  inflamed  or  congested 
viscus  by  the  application  of  intense  moist  and  dry  heat 
to  the  skin  surface,  and  the  circulation  through  any  of  the 
viscera  may  be  variously  influenced  by  the  alternate  appli- 
cation of  heat  and  cold.  In  this  way  morbid  processes  may 
be  powerfully  influenced  and  functional  activity  increased. 

The  drinking  of  very  hot  water,  in  sips,  excites  both  the 
motor  and  secretory  activity  of  the  gastric  wall  and  stimu- 
lates the  circulation. 

Very  hot  and  cold  applications  to  the  epigastrium  also 
increase  both  secretion  and  peristaltic  activity.  Warm 
applications  have  the  reverse  effect. 

By  hot  applications  to  the  right  hypochondrium  increased 
secretion  of  bile  is  induced,  and  the  hepatic  circulation 


GENERAL  PRINCIPLES  61 

generally  stimulated.  This  action  is  increased  if  a  hot 
fomentation  be  followed  by  a  "  heating ' '  compress.  Distinct 
contraction  of  the  spleen  is  effected  by  similar  treatment. 

A  general  hot  application,  sufficient  to  induce  free 
perspiration,  greatly  relieves  acute  or  subacute  inflammation 
of  the  kidneys;  a  hot  bath,  short  of  perspiration,  increases 
renal  activity  and  promotes  free  flow  of  urine. 

General  Indications. — The  stimulating  effects  of  heat 
are  utilized  in  dealing  with  conditions  of  extreme  exhaustion 
from  over-exertion  or  toxaemia.  The  diaphoretic  effect 
of  heat  is  of  immense  value  in  the  treatment  of  many 
conditions — e.g.,  acute  and  chronic  rheumatism,  severe 
chill,  uric  acid  diathesis,  diabetes,  parasyphilides,  bronchial 
catarrh,  chronic  inflammations  of  the  gastro-intestinal 
tract,  kidneys,  or  pelvic  viscera. 

Deep-seated  inflammations  are  treated  by  means  of 
local  applications  to  the  appropriate  cutaneous  surface 
or  by  general  applications.  In  pelvic  inflammation,  e.g., 
pain  is  greatly  relieved  by  a  hot  hip  pack,  a  general  blanket 
pack,  or  hot  full  bath. 

Toleration  of  Exposure  to  Heat. — The  degree  of  heat 
which  can  be  safely  borne  by  a  human  being  is  dependent 
on  the  rarity  or  density  of  the  medium  supplying  the  heat, 
and  its  capacity  for  absorbing  moisture.  When  a  medium 
is  very  absorbent,  perspiration  is  encouraged  and  scalding 
avoided,  even  when  a  very  high  temperature  is  employed. 
A  full  bath  at  a  temperature  of  45°  C.  is  tolerable  for 
eight  minutes  by  the  average  European  (the  Japanese  can 
take  considerably  hotter  baths  with  comfort  and  safety). 
General  hot-air  baths  of  127°  C.  can  be  borne  for  the  same 
time,  and  local  hot-air  applications  at  considerably  higher 
temperatures.  Sweating  is  easy  in  a  hot-air  bath,  more 
difficult  in  vapour  baths,  and  most  of  all  in  hot- water  baths. 

The  Basis  of  Hydrotherapeutic  Applications. — For  an 
intelligent  understanding  of  the  therapeutic  effects  of  hot  and 
cold  applications  one  must  consider  the  anatomical  facts. 
The  effects  resulting  from  applications  of  heat  and  cold  to 
the  body  surface  depend  on — 

1.  The  general  body  temperature  and  the  temperature 
induced  locally  by  the  application. 


62          MANUAL  OF  PHYSIO-THERAPEUTICS 

2.  The   remote   changes   reflexly   produced   by   nervous 

influence. 

3.  The  local  vascular  connections. 

Nerve  Reflexes. — As  regards  nervous  influence,  there  are 
definite  cutaneous  reflex  areas  for  each  viscus  from  which 
the  most  intense  reflex  impressions  are  received. 

The  theory  of  counter-irritation  is  dependent  on  the 
correlation  of  the  afferent  visceral  and  somatic  nerves,  to 
which  is  also  due  the  well-known  phenomenon  of  ' '  referred 
pain."  The  existence  of  definite  cutaneous  reflex  areas  for 
each  viscus  has  been  above  referred  to.  If,  from  disease,  a 
centripetal  impression  originates  in  any  viscus,  this  induces 
a  further  stimulation  in  the  nerve  fibres  coming  from  the 
corresponding  segmental  skin  area,  and  gives  rise  to 
"  referred  pain." 

The  afferent  visceral  and  cutaneous  nerve  fibres  come 
into  close  relation  in  the  ganglion  of  the  posterior  root,  and 
the  reflex  impulse  starts  here  or  in  the  grey  matter  of  the  cord. 

Conversely,  any  form  of  counter-irritation  on  the  appro- 
priate skin  area  in  visceral  disease  usually  acts  beneficially. 

Vascular  Areas. — It  has  already  been  demonstrated  that 
there  is  an  intimate  and  direct  relation  between  the  visceral 
bloodvessels  and  the  superincumbent  cutaneous  vessels. 
There  are  particularly  free  and  ample  connections  with 
the  skin  surface  as  regards  the  brain,  middle  ear,  nose,  and 
orbit.  The  vessels  of  the  lungs  are  related  collaterally 
with  the  skin  over  the  arms,  chest,  and  upper  portion  of 
the  back.  The  pericardium  and  parietal  pleura  of  the 
interior  portion  of  the  chest  are  related  with  the  overlying 
skin  through  the  intercostal  arteries.  The  posterior  parietal 
and  visceral  pleura  are  collaterally  related  with  the  inter- 
costal vessels.  In  addition,  there  are  free  connections 
through  the  inferior  thyroid  and  the  bronchial  arteries, 
the  azygos,  bronchial,  and  intercostal  veins.  The  kidneys 
are  associated  with  the  skin  covering  the  loins  through 
the  renal  branches  of  the  lumbar  arteries.  There  is  a 
collateral  venous  and  arterial  relationship  between  the 
stomach,  liver,  spleen,  intestines,  and  pancreas.  The 
intimate  relationship  between  the  portal  and  general 
circulation  is  well  known 


GENERAL  PRINCIPLES 


63 


Brain 


FIG.  20. — ANTERIOR  CUTANEOUS  AREAS  REFLEXLT  ASSOCIATED 
WITH  INTERNAL  PARTS. 


64          MANUAL  OF  PHYSIO-THERAPEUTICS 


Brain 


Pelvic  Viscera 


I  Genitourinary 
Organs 

Bowels  &  Brain 


FIG.  21. — POSTERIOR  CUTANEOUS  AREAS  REFLEXLY  ASSOCIATED 
WITH  INTERNAL  PARTS. 


GENERAL  PRINCIPLES 


65 


In  similar  manner  the  upper  portions  of  the  body  are 
related  to  the  lower.  The  regions  below  the  umbilicus 
are  collaterally  related  with  the  head,  arms,  and  upper 
half  of  the  trunk ;  the  legs  have  a  close  collateral  connection 
with  the  pelvic  viscera. 


.  Dccajcd  teeth. 
.Pharynj 


FIG.  22. — CUTANEOUS  AREAS  ASSOCIATED  REFLEXLY  WITH 
VISCERAL  PAIN  (DANA). 

With  these  facts  before  us  it  is  easy,  therefore,  to  under- 
stand how  the  volume  of  blood  in  any  viscus,  it  matters 
not  how  remote  from  the  surface,  may  be  diminished,  either 
by  a  general  hot  application  to  the  skin,  or  by  a  local  appli- 
cation to  a  less  extent.  In  this  manner  is  to  some  extent 
explained  the  good  effect  of  a  hot  foot  bath  or  sitz  bath  on 

5 


66          MANUAL  OF  PHYSIO-THERAPEUTICS 

an  arterial  congestion  or  common  cold,  the  relief  afforded  to 
infantile  croup  by  a  hot  sponge  on  the  larynx,  and  the 
comfort  afforded  by  a  fomentation  to  an  aching  stomach 
or  an  ice-bag  to  a  dry  pleurisy. 

The  facts  above  considered  constitute  the  scientific  basis 
for  many  thermal  and  hydrotherapeutic  applications, 
and  for  the  whole  practice  of  counter-irritation.  For 
our  knowledge  of  the  various  communications  between 
the  skin  areas  and  the  viscera  dealt  with  above  we  are 
indebted  chiefly  to  the  work  of  Winternitz,  Foster, 
and  Head. 

The  Internal  Administration  of  Water. 

1.  By  the  Mouth. — Water,  when  introduced  into  the 
tomach,  is  taken  up  by  the  tissues  of  the  body  with  greater 
or  less  rapidity,  and  remains  in  contact  with  the  tissues  for 
a  considerable  period  of  time.  It  comes  into  immediate 
contact  with  the  various  portions  of  the  digestive  canal. 
It  has  a  special  influence  on  the  most  intimate  nutritive 
processes  by  reason  of  its  chemical  constitution  and  the 
equalization  of  its  temperature  with  that  of  the  body.  It 
further  renders  the  tissues  throughout  the  body  permeable 
by  all  water-soluble  substances  taken  in  the  form  of  food. 

The  effect  of  drinking  a  quart  of  cold  (18°  C.)  water 
rapidly  is  to  diminish  the  pulse  frequency  by  22  beats  in 
thirty  seconds ;  in  ten  to  twelve  minutes  it  becomes  normal 
again.  If  the  water  temperature  be  lower  the  pulse  declines 
rather  more  rapidly. 

The  temperature  of  the  body  declines  with  the  pulse-beats 
to  the  extent  of  about  0-5°  C.,  but  in  about  ten  minutes 
returns  to  the  previous  level. 

By  drinking  cold  water  the  temperature  of  the  stomach 
is  lowered  considerably — to  the  extent  of  at  least  0-5°  C.— 
and  the  original  temperature  is  not  regained  for  several 
hours.  If  the  rectal  temperature  be  taken,  it  will  be  found 
that  a  lowering  of  over  1°  0.  takes  place  rapidly,  and  this 
lower  temperature  is  continued  for  upwards  of  an  hour. 
An  intimate  reaction  evidently  exists  between  stomach  and 
rectum,  for  if  a  person  be  given  a  large  cold-water  enema. 


67 

the  temperature  of  the  stomach  declines  nearly  1°  C. 
(Winternitz). 

It  is  thus  evident  that  the  body  temperature  can  be 
influenced  by  the  imbibition  of  water,  and,  further,  the 
temperature  of  various  deep-seated  organs  can  also  be 
influenced.  There  is  a  sound  basis  furnished  for  the  pre- 
scribing of  systematic  water  drinking,  and  the  marked  local 
and  general  therapeutic  effects  obtained  are  explained.  It 
must  be  borne  in  mind  that  the  vasomotor  system  also 
has  considerable  influence. 

The  rapidity  with  which  the  absorption  of  water  takes 
place  depends  on  a  variety  of  circumstances.  The  lower 
the  blood  pressure  at  the  moment  of  taking  the  water, 
the  more  rapidly  will  it  be  absorbed  into  the  bloodvessels. 
After  considerable  fluid  loss  from  the  body  owing  to  normal 
or  pathological  causes — such  as  free  diuresis,  profuse 
perspiration,  diarrhoea,  or  bleeding — rapid  absorption  of 
fluid  from  the  intestinal  tract  will  take  place. 

Pure  spring  water,  containing  little  saline  matter,  is  more 
rapidly  taken  up  by  the  blood-stream  than  water  containing 
much  saline  matter.  A  carbonaceous,  gaseous  water  is 
more  grateful  to  the  stomach,  and  more  rapidly  absorbed, 
than  a  still  alkaline  water,  which  may  cause  gastric  dis- 
comfort and  "  fulness,"  even  if  drunk  in  small  quantity. 

After  free  consumption  of  water  the  blood  is  somewhat 
diluted  temporarily,  and  the  blood-pressure  rises.  The 
larger  the  quantity  of  water  drunk,  the  greater  and  the 
more  enduring  is  the  effect  on  the  blood-pressure,  which 
does  not,  however,  continue  for  above  three  and  a  half 
minutes.  The  increase  of  the  water  in  the  blood  can  only 
be  demonstrated  for  a  very  short  time.  In  less  than  an 
hour  the  blood  has  regained  its  former  density.  In  one 
hour  water  which  has  been  imbibed  begins  to  appear  in  the 
tissues,  and,  normally,  the  entire  amount  is  eliminated  in 
three  and  a  half  hours.  Large  quantities  are  relatively 
more  rapidly  eliminated  than  small  quantities.  It  follows 
that  such  a  condition  as  hydra?mic  plethora  is  an  impossi- 
bility, even  when  excessive  quantities  of  water  are  consumed. 
Not  only  is  this  so,  but  the  drinking  of  cold  water  acts  as 
a  diuretic,  and  aids  in  the  removal  of  water  not  recently 


68          MANUAL  OF  PHYSIO-THERAPEUTICS 

imbibed.  Warm  water,  while  it  will  for  a  short  time 
stimulate  the  kidneys  to  increased  action,  soon  results  in 
perspiration.  The  diuretic  action  of  water  depends  not  so 
much  on  the  quantity  actually  imbibed  as  on  the  general 
increase  of  blood-pressure  and  freer  circulation  through  the 
kidneys  at  greater  pressure.  With  the  increased  output  of 
water  the  solid  constituents  of  the  urine  are  also  increased, 
especially  urea  and  uric  acid. 

Method  of  Prescribing. — The  method  adopted  in  pre- 
scribing water  wrill  obviously  vary  with  the  effect  we  wish 
to  produce. 

If  we  desire  to  flood  the  body  tissues  and  raise  the  blood- 
pressure,  water  is  given  in  single  small  doses  of  5  or  6  ounces, 
repeated  every  twenty  minutes  or  half -hour  for  a  considerable 
time. 

On  the  other  hand,  if  the  object  is  to  promote  the  absorp- 
tion of  fluid  transudates,  a  pint  or  more  of  water  should  be 
given  every  six  to  eight  hours,  and  all  fluids  withheld  in  the 
interval.  Not  only  may  the  removal  of  dropsy  or  other 
effusion  be  thus  greatly  helped,  but  the  absorption  of  im- 
flammatory  exudates  is  greatly  accelerated. 

The  loss  from  the  body  is  greatly  increased  by  the  free 
drinking  of  water,  and,  food  being  restricted,  the  blood 
regenerates  itself  from  the  tissues,  leading  to  a  retrogressive 
metamorphosis. 

While  moderate  consumption  of  water,  with  suitable  food, 
causes  a  gain  in  body-weight,  excessive  water  drinking 
causes  loss  of  weight. 

The  processes  of  oxidation  are  stimulated  and  rendered 
more  efficient,  as  can  be  demonstrated  by  the  large  quanti- 
ties of  CO.,  eliminated  and  the  small  quantity  of  uric  acid 
and  kreatinins  formed  in  the  blood.  Metabolism  throughout 
the  whole  body  is  increased  and  accelerated. 

The  chilling  of  the  stomach  caused  by  drinking  cold 
water  (vide  supra]  evidences  the  undesirability  of  excessive 
drinking  during  meals.  Apart  from  this,  the  drinking  of 
cold  water  stimulates  the  liver,  quickens  the  flow  in  the 
portal  vein,  and  increases  the  secretion  of  bile. 

2.  By  the  Rectum. — Rectal  injections  of  water  at  various 
temperatures  are  used  for  many  purposes — e.g.,  to  procure 


GENERAL  PRINCIPLES  69 

an  action  of  the  bowels,  to  restrain  diarrhoea,  to  soothe  pelvic 
pain,  to  get  rid  of  intestinal  parasites,  particularly  Oxyuris 
vermicularis,  and  to  compensate  for  fluid  loss  from  hsemor- 
rhage  or  otherwise.  So  far  as  relief  of  the  bowels  is  con- 
cerned, it  must  be  clearly  understood  that  an  enema  seldom 
accomplishes  its  purpose  by  merely  washing  away  fsecal 
matter.  As  a  matter  of  fact,  it  quite  often  scarcely  reaches 
the  feecal  matter,  which  may  lie  high  up  in  the  colon.  It 
rather  effects  its  purpose  by  inducing  a  more  vigorous 
peristaltic  action. 

By  the  distension  with  water  of  the  lower  portion  of  the 
bowel  a  local  vermicular  action  is  started  which  spreads 
along  the  bowel.  If  the  enema  be  too  small  in  bulk,  disten- 
sion of  the  rectum  is  not  effected  and  failure  results. 

The  amount  as  well  as  the  temperature  of  the  water 
required  varies  greatly  with  circumstances  and  individuals. 
Anything  from  half  a  pint  to  three  or  four  pints  or  more 
may  be  needed.  Warm  and  hot  enemata  are  more  stimu- 
lating and  effective  than  cold. 

If  a  large  injection  is  to  be  given,  the  patient  should  lie 
on  his  left  side  with  knees  drawn  up,  and  fluid  be  slowly 
pumped  into  the  rectum.  After  a  varying  time  the  patient 
feels  unable  to  retain  more,  and  has  a  colicky  pain  in  the 
abdomen,  and  desires  to  relieve  the  bowels ;  this  desire  may 
be  gratified,  or,  if  a  large  enema  is  deemed  necessary,  the 
patient  is  asked  to  endeavour  to  retain  the  water,  and  helped 
by  means  of  a  folded  towel  pressed  over  the  anus,  pumping 
having,  of  course,  ceased  in  the  meantime.  The  desire  to 
defsecate  will  soon  pass  off,  and  then  more  water  can  be 
introduced.  It  is  often  more  convenient  to  use  a  douche-can, 
and  allow  the  water  to  enter  by  gravity  only.  Less  straining 
is  thus  induced,  and  by  this  means  the  patient  can  carry 
out  the  procedure  unassisted. 

When  complete  irrigation  of  the  colon  is  desired,  as  many 
as  six  to  eight  pints  may  be  introduced  by  this  method;  but 
the  frequent  use  of  large  enemata  induces  eventually  an 
atonic  condition  of  the  bowel,  and  the  last  state  of  the 
patient  is  worse  than  the  first. 

In  some  cases,  when  constipation  is  obstinate  and  long- 
standing, as  is  common  in  mental  disease  and  diabetes,  the 


70          MANUAL  OF  PHYSIO-THERAPEUTICS 

injected  water  may  come  away  quite  clear,  and  have  no 
relieving  action  on  the  bowels.  Under  such  circumstances, 
if  even  warm  eiiemata  do  not  accomplish  their  purpose, 
kneading  the  abdomen  along  the  course  of  the  colon  must 
be  employed  as  an  adjuvant,  and  even  actual  removal  of 
the  fseces  by  digital  efforts  or  a  spoon  may  be  necessary. 

Where  it  is  desired  to  introduce  fluid  to  be  actually 
retained  and  absorbed  by  the  patient,  the  use  of  a  long 
rectal  tube  is  often  an  advantage. 


FIG.  28. — THE  PLOMBIKRES  DOUCHE. 

Warm  injections  often  materially  lessen  the  pain  of  cancer 
of  the  bowel,  and  relative  distressing  tenesmus  and  straining. 
They  are  also  of  use  in  cystitis,  prostatic  abscess,  and  para- 
metritis.  Irrigation  of  the  colon  for  chronic  mucous  colitis 
is  now  very  extensively  employed,  a  special  feature  being 
made  of  it  at  Harrogate. 

In  gastric  dilatation,  etc.,  where  it  is  desired  to  give  the 
stomach  a  complete  rest  from  fluid,  the  tissues  may  be  kept 
properly  supplied  per  red,  im  with  great  ease,  and  much 
to  the  patient's  comfort  and  well-being. 


71 

The  value  of  large  injections  of  plain  or  slightly  alkaline 
water  in  the  condition  of  mucous  colitis  has  long  been  known. 
Recently  this  has  been  done  from  above  downwards  by 
means  of  a  small  opening 
formed  for  the  purpose  in  the 
colon  by  the  operation  of 
appendicostomy. 

Irrigation. 

Vaginal  Douching  or  Irriga- 
tion (as  Kellogg  thinks  it  should 
more  properly  be  called). — This 
consists  in  the  injection  into 
the  vaginal  canal  of  a  stream 
of  cold,  hot,  or  tepid  water, 
under  but  slight  pressure. 

Its  value  in  various  uterine, 
ovarian,  and  other  pelvic  dis- 
orders to  which  women  are 
subject  is  generally  recognized. 

To  obtain  the  best  results 
some  little  attention  to  the 
details  of  the  technique  is 
requisite.  A  gravity  syringe  is 
usually  employed,  the  water 
being  contained  in  a  can  or 
glass  reservoir  which  rests  on 
a  shelf  or  stool  some  3  feet 
above  the  patient,  or  special 
appliances  are  made  (Fig.  24). 
The  water  is  conducted  to  the 
vagina  by  means  of  a  rubber 
tube  terminating  in  a  glass  or 
vulcanite  nozzle.  The  patient 
lies  on  her  back,  and  the  water 
passes  out  of  the  vagina  into  a  suitable  receptacle  arranged 
to  catch  it.  Kellogg  has  devised  a  special  form  of  table 
made  of  marble.  The  table  being  hollowed  to  fit  the 
patient's  back,  and  an  opening  provided  to  conduct  the 


FIG.  24. — AN  ADJUSTABLE 
GRAVITY  SYRINGE. 


72  MANUAL  OF  PHYSIO-THERAPEUTICS 

water  rapidly  away  without  wetting  the  patient's  clothing, 
asepsis  is  specially  easy  to  maintain. 

In  introducing  the  vaginal  tube,  care  is  needed  to  pass 
it  into  the  posterior  vaginal  fornix  as  far  as  possible,  and 
thus  avoid  any  chance  of  injecting  the  water  into  the  uterine 
cavity. 

The  idea  is  to  allow  the  water  to  circulate  freely  around 
the  neck  of  the  uterus  and  in  the  vagina,  bringing  every 
part  under  its  influence.  The  mucous  membrane  is  directly, 
and  the  pelvic  viscera  reflexly,  affected. 

Effects. — Both  hot  and  cold  applications  are  useful  in 
relieving  haemorrhage  due  to  uterine  congestion,  chronic 
metritis,  etc.  Cold  water  is  generally  more  efficient  in  this 
respect  than  hot.  Hot  douches  lessen,  and  even  completely 
arrest,  uterine  contractility  and  excitability,  which  cold 
douching  increases.  Further,  cold  douches  may  cause 
painful  uterine  contractions  and  aggravate  neuralgic 
uterine  and  pelvic  pains,  so  that  water  of  the  higher 
temperatures  is  most  commonly  employed.  A  douche  of  a 
temperature  of  32°  C.  is  of  great  service  in  relieving 
pelvic  congestions.  Temperatures  below  6°  C.  are  prac- 
tically never  employed,  but  a  douche  of  25°  to  27°  C.  is 
very  frequently  of  service. 

Very  hot  irrigations  are  employed  to  check  haemorrhage, 
a  temperature  of  50°  to  55°  C.  being  utilized.  Hot  irriga- 
tions of  45°  to  47°  C.  relieve  pain,  and  promote  the  absorp- 
tion of  exudates  in  parametritis  and  pelvic  cellulitis ;  they 
are  of  service  in  chronic  metritis,  ovaritis,  and  endometritis. 

For  intra-uterine  irrigation  only  distilled  or  sterilized 
water  must  be  used. 

Rectal  Irrigation. — The  rectal  irrigator  (Fig.  25),  or 
psychrophore  of  Artzberger,  is  a  faucet-like  hollow  in- 
strument, permitting  the  inflow  and  outflow  of  water,  the 
temperature  of  which  will  vary  with  circumstances. 

Before  introduction  into  the  rectum,  the  irrigator  should 
be  well  lubricated  with  vaseline  or  lanolin,  and  the  patient 
—placed  in  a  suitable  posture — asked  to  "  bear  down." 

The  temperature  of  the  water  (which  should  be  flowing 
from  an  ordinary  douche-can  at  an  elevation)  used  at  the 
commencement  should  not  be  lower  than  20°  C.  in  most  cases ; 


GENERAL  PRINCIPLES  73 

and  if  there  be  any  inflammatory  condition  in  the  bladder 
neck,  very  disagreeable  strangury  and  tenesmus  may  be 
excited. 

The  effect  of  the  application  is  tonic,  and  to  some  extent 
soothing  and  anesthetic.  This  procedure  is  serviceable 
in  haemorrhoids  and  in  various  chronic  inflammatory  con- 


FIG.  25. — EECTAL  IKBIGATOR. 

ditions  of  the  rectum  and  its  vicinity.  Hot  and  cold  water 
alternately  are  variously  employed,  according  to  the  effect  it 
is  desired  to  produce. 

The  Psychrophore,  or  Cooling  Urethral  Sound. — This 
resembles  an  ordinary  two-way  catheter,  and  is  introduced 
in  the  same  way.  It  should,  however,  stop  short  of  the 
vesical  cavity  just  as  the  sphincter  vesicae  grips  it.  A  fairly 
large  size  (Nos.  12  to  14)  is  generally  used,  at  any  rate  after 
the  first  time.  The  water  temperature  should  at  first  be 
20°  to  22°  C.,  and  reduced  to  10°  C.  gradually.  The  patient 


FlG.    26. WlNTERNITZ'S    URETHRAL    PSYCIIROPIIORE. 

should  be  told  to  empty  his  bladder  prior  to  the  introduction 
of  the  sound.  Some  vesical  tenesmus  may  occur  at  first, 
but  soon  passes  off;  the  effect  of  the  treatment  is  soothing 
and  tonic.  At  first  the  sound  should  be  allowed  to  remain 
in  for  about  five  minutes,  and  then  gradually  a  longer  period 
up  to  half  an  hour,  using  it  on  alternate  days. 


74          MANUAL  OF  PHYSIO-THERAPEUTICS 

THERAPEUTIC  INDICATIONS. — It  is  useful  both  in  nocturnal 
enuresis  in  adult's  and  in  testicular  neuralgia ;  also  in  atonic 
psychical  impotence,  spermatorrhoea,  prostatorrhcea,  and 
chronic  gleet — a  very  large  bore  being  advisable  in  the  last 
affection,  as  first  advised  by  Keyes. 

Colon  Douching — The  Technique  of  Irrigation,  or  the 
Plombieres  Douche. — This  may  be  done  in  a  bedroom  with 
an  ordinary  gravity  douche-can  and  rubber  tubing,  but  it 
is,  of  course,  preferably  done,  as  at  Harrogate  and  other 
health  resorts,  by  means  of  the  complete  Plombieres  outfit. 

It  may  be  carried  out  with  a  single  tube,  using  a  two-way 
tap  apparatus  or  its  equivalent,  or  by  means  of  a  simple 
funnel  and  tube,  or  with  a  double-current  rectal  tube. 

The  two-way  tap  apparatus  consists  of  a  douche-can  and 
two-way  tap,  one  arm  of  which  is  attached  to  the  douche- 
can  by  means  of  a  rubber  tube;  another  terminates  in 
stomach  tube  with  terminal  and  lateral  eyes;  while  the 
remaining  arm  enters  a  third  rubber  tube,  which  leads  into  a 
receptacle  beside  the  couch  or  bed  on  which  the  patient  lies. 

The  patient  lies  on  his  left  side,  and  the  end  of  the  rubber 
stomach  tube  is  passed  about  4  inches  up  into  the  bowel. 
Water  is  now  allowed  to  enter  from  the  douche-can  with 
about  1  to  1 1  feet  of  "  head."  When  enough  has  entered, 
the  tap  is  adjusted  for  outflow  to  the  receptacle  on  the  floor. 

It  is  well  to  bear  in  mind  clearly  that  the  water  has  to 
find  its  own  way  up  to  the  "  higher  reaches  "  of  the  colon, 
unless  the  tube  be  very  long — viz. ,  about  a  yard.  The  rectum 
is  8  inches  long  and  sigmoid  1 7-|-  inches — a  point  worth  re- 
membering. In  place  of  the  stomach  tube  special  colon 
tubes  about  10  inches  long  are  supplied  at  Harrogate,  made 
of  fairly  thick  rubber  and  tapered.  Each  patient  has  his 
own  tube. 

A  definite  amount  of  fluid  is  allowed  to  enter  the  bowel  and 
a  definite  amount  allowed  to  leave,  with  a  prearranged 
quantity  allowed  to  remain.  Every  douche-can  should 
have  a  graduated  front  of  glass,  and  the  tube  of  exit  should 
pass  into  a  large  measure  first. 

The  patient  lies  upon  his  left  side  with  hips  well  raised 
by  sandbags  or  similar  medium,  while  a  pint  or  so  of  water 
is  introduced  into  the  rectum. 


GENERAL  PRINCIPLES  75 

The  patient  then  gets  up  and  evacuates  the  bowel,  as 
this  preliminary  douche  is  for  that  purpose.  The  original 
posture  is  then  resumed  and  the  irrigation  continued.  In 
some  cases  it  is  requisite  to  employ  the  knee-chest  position 
to  secure  the  fluid  passing  up  the  bowel. 

Irrigation  by  a  double-current  tube  is,  of  course,  quite 
different,  as  the  fluid  enters  the  bowel  by  one  tube  and 
leaves  by  the  other.  A  soft  double-current  tube  (French 
make)  is  usually  employed.  The  irrigator  is  attached  to 
two  tubes,  one  of  which  is  connected  with  the  douche-can 
or  cistern,  and  the  other  passing  to  some  suitable  receptacle 
below  the  bed  or  couch  on  which  the  patient  is  lying.  Well 
lubricated,  it  is  introduced  into  the  bowel  with  a  gentle 
rotatory  motion,  the  tube  being  directed  slightly  back- 
wards. The  inlet  and  outlet  tubes  are  so  arranged  that  the 
amount  of  water  leaving  and  entering  the  bowel  are  equal. 
If  a  certain  amount  be  allowed  to  enter  the  bowel  before 
any  escape  occurs,  this  will  remain  constant  and  in  contact 
with  the  bowel,  though  always  changing  with  the  flow  of  the 
water.  Fresh  water  or  solution  is  thus  brought  into  contact 
with  the  mucous  membrane.  The  amount  left  in  varies  from 
a  few  ounces  to  1-|  pints  or  more,  according  to  the  surface  of 
the  bowel  it  is  requisite  to  deal  with.  Kemp's  instructions 
for  irrigating  the  whole  of  the  colon  as  far  as  the  caecum 
are  as  follows : 

1 .  Place  the  patient  on  the  left  side  with  the  hips  elevated, 
and  the  descending  colon  is  freely  irrigated. 

2.  Turn  the  patient  over  gradually  to  dorsal  position  and 
then  to  the  right  side,  with  the  hips  elevated;  pinch  the 
return  tube  so  that  about  1|-  pints  are  allowed  to  run  into 
the  bowel. 

3.  Raise  the  shoulders  above  the  hips,  patient  being  still 
on  the  right  side.     The  fluid  is  thus  made  to  gravitate  on 
to  the  caput  coli. 

4.  Then  depress  the  shoulders  below  the  hip  level,  turning 
the  patient  back  to  the  dorsal  position  and  left  side — in 
short,  reverse  the  first  manoeuvre.     The  return  tube  is  then 
let  go  and  the  w'ater  escapes. 

The  temperature  of  the  water  used  will  vary  with  the 
state  of  the  mucous  membrane.     Plain  water  or  normal 


76          MANUAL  OF  PHYSIO-THERAPEUTICS 

saline  is  the  best  and  safest  medium  to  use,  but  various 
medicaments  are  added  at  times,  such  as  tannic  acid,  boracic 
acid,  permanganate  of  potash,  ichthyol,  and  protargol, 
which  last  in  -g  per  cent,  strength  we  have  found  most  useful 
in  mucous  colitis.  At  Harrogate  the  sulphur  water  is 
commonly  employed. 

Such  irrigation  should  be  regularly  employed  during  the 
first  three  weeks  of  the  treatment  of  colitis  of  chronic  type. 
It  is  a  very  healing  and  soothing  measure  in  chronic  ulcera- 
tion,  and  if  there  be  any  considerable  degree  of  toxaemia. 
We  have  known  very  distressing  eczema  afforded  quick  relief 
by  this  procedure. 

The  elaborate  Plombieres  couch  (Fig.  23),  as  used  at 
Harrogate,  etc.,  is,  of  course,  a  refinement  or  amplifica- 
tion of  the  treatment,  but  most  necessary  where  large 
numbers  of  patients  are  passed  through  daily.  The  couch 
used  is  about  the  size  of  a  short  single  bed,  and  in  the 
centre  is  an  aperture  similar  to  that  in  an  ordinary  w.c.  seat, 
through  which  the  patients  evacuate  the  bowel  after  the  first 
washing.  The  faeces  are  washed  away  from  a  grid  or  netting 
by  the  attendant,  and  the  amount  of  mucus  passed  more 
or  less  estimated  by  the  attendant,  who  registers  it  on  the 
patient's  chart.  Careful  note  is  thus  kept  of  his  progress. 

Needless  to  say,  many  patients  cannot  have  such  an 
equipment  readily  available,  and  with  these  quite  adequate 
douching  can  be  carried  out  with  the  gravity  douche-can  at 
home. 

The  immediate  effect  on  patients  varies.  Many  feel  quite 
fresh  and  brisk  at  once  after  the  treatment  and  capable 
of  taking  exercise,  but  the  more  feeble  are  inclined  to  feel 
collapsed  and  require  a  prolonged  rest  to  regain  their 
equilibrium. 

At  a  large  spa  there  is  often  a  rush  for  appointments,  and 
early  appointments  even  before  breakfast  may  be  necessary. 
Such  times  should  be  avoided  except  by  those  who  are 
robust. 


CHAPTER  II 
ON  THE  TAKING  OF  BATHS 

THE  technique  of  hydrotherapy  has  reached  a  very  high 
degree  of  development,  and  such  a  variety  of  baths  are 
employed  at  the  present  day,  and  there  are  so  many  modi- 
fications of  them,  that  it  is  now  possible  to  adapt  special 
hydriatric  procedures  to  each  individual  case  coming 
before  us  for  treatment. 

In  every  variety  of  bathing  procedure  the  points  of  the 
highest  importance  are  the  temperature  of  the  water  applied, 
the  amount  of  pressure  under  which  it  is  applied,  the 
friction  produced,  and  the  duration  of  the  application. 
By  varying  these,  the  same  effects  can  be  produced 
by  very  different  methods.  Winternitz  lays  great  stress 
on  the  importance  of  the  measure  of  stimulation  in 
each. 

It  is  customary  to  cool  the  head  thoroughly  before  every 
cool  or  warm  application,  and  to  keep  it  wrapped  up  in 
some  cool  covering  during  the  whole  of  the  process.  This 
helps  to  prevent  ill  effects  through  the  blood  being  driven 
inwards  by  the  cooling  of  the  skin  surface,  and  inducing 
what  Winternitz  calls  "  retrograde  hydrostatic  congestion  " 
of  any  of  the  internal  organs,  but  more  especially  the 
brain. 

If  a  hot  application  be  used,  cooling  of  the  head  is  also 
desirable;  for  here  again  internal  congestion  is  caused,  and 
in  old  and  plethoric  patients  there  is  a  tendency  to 
apoplexy. 

It  is  of  course  essential  when  any  bath  is  ordered  by 
a  physician  that  a  specific  statement  be  made  as  to  the 
temperature  of  the  water  to  be  employed  and  the  duration 
of  the  application. 

77 


78          MANUAL  OF  PHYSIO-THERAPEUTICS 

General  Precautions  as  to  the  Taking  of  Baths. 

1.  A  careful  examination  of  the  cardio-vascular  system 
should  be  made  before  the  physician  prescribes  any  bath 
or  set  of  baths. 

2.  Extreme   temperatures   are    specially   undesirable    in 
children  and  elderly  people,  and  also  in  women  at  the  time 
of  the  climacteric.     During  the  catamenial  flow  hydriatric 
procedures  should  for  the  most  part  be  suspended. 

3.  Every  bath  has  an  effect  which  is  either  stimulant  or 
sedative;    which    of   these   predominates    will    depend    on 
various  circumstances,  such  as  the  range  of  temperature 
and  duration  of  the  procedure,  also  the  time  of  the  day  and 
general  condition  of  the  patient. 

4.  Care  is  very  necessary  not  to  prolong  thermal  baths 
sufficiently  to  cause  depression  or  lassitude. 

5.  Hot-air  and  vapour  baths  should  never  be  employed 
in  febrile  conditions,  unless  in  incipient  catarrhal  conditions 
and  chills. 

6.  Too  stimulating  procedures  or  a  prolonged  course  of 
treatment  are  often  followed  by  circulatory  depression  and 
considerable  debility. 

7.  In  chronic  diseases,  during  the  first  week  or  two  of 
treatment  there  is  often  some  exacerbation  of  symptoms, 
which   is  not  an  unfavourable  sign,   and  passes   on  into 
healthier  conditions. 

8.  Physical  exercise  usually  requires  some  modification 
during  a  course  of  bathing,  etc.     The  reaction  of  the  cooling 
processes  is  hastened  and  assisted  by  a  short  brisk  walk; 
rest  and  cooling  are  frequently  beneficial  after  warm  applica- 
tions.    If  much  exercise  be  taken  during  a  full  course  of 
treatment,  loss  of  weight  will  result. 

9.  After  a  course  of  hydrotherapeutic  treatment,  a  change 
to  a  more  bracing  climate,   or  a  short  sea  trip,   is  often 
beneficial.     This  constitutes  what  is  known  on  the  Continent 
as    the    "  after-cure."     Patients    who   feel  exhilarated  by 
their    better    health   should  be  warned  not   to   overexert 
themselves  and  so  induce  a  relapse. 


ON  THE  TAKING  OF  BATHS  79 


The  Technique  of  Baths— Partial  and  General. 

The  Arm  Bath. — This  is  chiefly  used  in  surgical  cases, 
in  severe  burns  and  skin  diseases  (Fig.  28),  and  requires 
no  detailed  notice  here. 

The  Foot  Bath. — The  bath  itself  is  a  familiar  household 
utensil,  made  either  of  metal,  porcelain,  or  wood,  and 
requires  no  further  description  (Fig.  27).  There  are,  how- 
ever, many  varieties  of  application  of  the  bath  so  far  as  the 
temperature  and  duration  are  concerned.  The  following 
are  the  most  important : 


A.N    IMPROVED    FOOT    BATH. 


1.  Cold. — Two  inches  deep,  for  thirty  minutes,  the  feet 
to  be  kept  on  the  move  all  the  time  and  rubbed  against  each 
other.  The  action  of  the  bath  is  intensified  if  the  water  is 
flowing  through  the  vessel  used,  and  thus  constantly  chang- 
ing and  always  at  the  same  temperature.  Water  of  a 
temperature  of  from  10°  to  15°  C.  is  commonly  employed. 
At  the  conclusion  the  feet  should  be  well  dried,  and  the 
patient  take  a  short  walk. 

This  bath  is  a  powerful  derivative,  inducing  a  hyperremia 
in  the  vessels  of  the  feet  and  legs.  It  helps  to  relieve  con- 
gestion of  the  brain  and  viscera,  and  is  of  high  value  in 
cases  of  habitually  cold  feet.  The  general  effect  is  tonic. 

Caution. — This  bath  should  not  be  used,  nor  indeed  any 
cold  foot  bath,  in  any  bladder,  rectal,  or  ovarian  inflamma- 
tion, nor  in  sciatica. 


80          MANUAL  OF  PHYSIO-THERAPEUTICS 

2.  Treading  in  cold  water,  1  inch  deep,  for  two  to  three 
minutes.     This  is  a  useful  measure  in  cases  of  cold  feet  from 
poor  circulation,  and,  given  at  bedtime,  for  insomnia. 

3.  Cold  sponging  of  feet  and  legs  over  a  bath,  one  limb  at 
a  time,  for  two  or  three  minutes.     The  feet  should  be  well 
rubbed  with  a  rough  towel  until  quite  dry,  and  a  brief  quick 
walk  taken.     The  action  is  similar  to  that  of  Nos.  1  and  2. 

4.  Alternate  Hot  and  Cold. — Two  foot  baths  are  placed  side 
by  side,  one  containing  hot  water  at  38°  C.,  and  the  other 
cold  at  18°  C.     The  patient's  feet  are  placed  in  the  hot 
water  for  half  a  minute,  and  then  shifted  to  the  cold  for  a 
like   period;    the   process   is   repeated   several   times,    the 
whole  bath  lasting  from  seven  to  ten  minutes,  and  finishing 
with  cold  water.     This  is  a  very  stimulating  form  of  the 
bath,  and  is  useful  in  chilblains,  in  early  Raynaud's  disease, 
and  in  habitually  cold  and  sweating  feet. 

5.  Hot. — Water  at  a  temperature  of   40°  to   50°  C.   is 
employed,  beginning  at  a  temperature  of  40°  to  42°  C.,  and 
gradually  increased.     The  feet  should  be  completely  im- 
mersed— indeed,  the  deeper  the  water  the  more  intense  the 
effect.     The  patient  sits  with  a  blanket  or  sheet  enclosing 
the  bath  and  limbs  as  high  as  the  waist.     The  duration  of 
the  bath  is  from  ten  to  twenty  minutes,  rarely  prolonged 
to  half  an  hour.     At  the  conclusion  the  feet  and  ankles 
should  be  sponged  with  cold  water  and  briskly  rubbed 
until  dry. 

6.  Very  Hot. — Water  up  to  51°  or  52°  C.,  as  hot  as  can  be 
borne,  is  used,  the  temperature  being  maintained  by  pouring 
a  cupful  of  boiling  water  against  the  side  of  the  bath  every 
two  minutes,  as  much  water  being  removed  in  advance; 
the   wrappings  should  be  as  little  disturbed  as  possible. 
Duration,  twenty  minutes. 

7.  Mustard. — A    breakfast-cupful    of    mustard    bran    or 
tablespoonful  of  table  mustard  is  used  for  each  quart  of 
water — of  a  temperature  of  48°  to  52°  C. — as  hot  as  can  be 
borne.     Duration,  fifteen  minutes,  or  less  if  uncomfortably 
hot. 

The  ultimate  effect  of  all  these  baths  is  to  render  the 
brain  anaemic  and  quicken  the  pulse-rate.  The  hot  foot 
bath  is  par  excellence  a  derivative  measure,  relieving  brain 


ON  THE  TAKING  OF  BATHS 


81 


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82          MANUAL  OF  PHYSIO-THERAPEUTICS 

and  visceral  congestions.  At  the  same  time  the  vascular 
activity  of  the  pelvic  viscera  is  increased,  and  by  means  of 
these  baths  delayed  or  suspended  menstruation  may  often 
be  brought  on.  The  value  of  a  hot  foot  bath  at  bedtime 
in  incipient  coryza  is  well  known,  its  action  being  intensified 
if  it  contain  mustard.  Whitla  also  recommends  this  in 
any  congestive  headache.  It  is  also  of  great  value,  com- 
bined with  elevation  of  the  hands,  in  epistaxis. 

The  Hand  Bath. — Immersion  of  the  hands  in  cold  water 
exercises  a  much  more  powerful  influence  on  the  pulmonary 
and  cerebral  vessels  than  would  be  naturally  expected 
(Kellogg).  The  pulse  is  slowed  and  the  pressure  in  the 
brain  arteries  lowered  by  the  use  of  a  cold  hand  bath,  while 
the  opposite  effect  is  induced  by  a  hot  hand  bath. 

In  epistaxis  the  bleeding  is  readily  checked  if  both  hands 
be  completely  immersed  in  cold  water,  or  a  piece  of  ice  be 
held  in  the  palm  of  the  patient's  hand.  In  the  same  way 
pulmonary  hemorrhage  may  be  beneficially  influenced. 

There  seems  to  be  some  reflex  connection  with  the  genito- 
urinary organs  also,  for  the  fact  that  placing  the  hands  in 
cold  water  often  causes  the  desire  for  micturition  is  well 


The  Head  Bath. — The  head  of  the  patient  should  rest 
comfortably  on  the  rim  of  a  suitable  vessel,  charged  to  within 
an  inch  of  the  brim  with  water  at  a  temperature  of  27°  C., 
which  is  continuously  taken  up  and  poured  over  the  patient's 
head  by  means  of  a  breakfast  cup.  After  fifteen  or  twenty 
minutes  of  this,  the  vessel  is  slipped  away  and  the  head  held 
up  by  the  hand.  A  towel  is  laid  loosely  over  the  hair  and 
another  is  laid  on  a  pillow  on  Avhich  the  head  is  now  rested. 
The  patient  is  left  thus  for  half  an  hour  or  more,  if  agreeable. 

Some  little  modification  is  required  in  the  case  of  women, 
on  account  of  their  usually  long  hair.  The  face  only  should 
be  dipped  into  the  bath,  or  if  the  whole  head  be  dipped, 
special  precautions  will  be  required  in  drying,  and  the 
patient  should  stay  indoors  for  some  hours  with  the  hair 
wrapped  up  in  a  silk  handkerchief. 

The  patient  lies  on  his  back,  with  the  shoulders  raised  by 
pillows  to  the  level  of  the  edge  of  the  bath,  from  the  sharp- 
ness of  which  the  back  of  the  neck  is  protected  by  means  of 


ON  THE  TAKING  OF  BATHS  8:5 

a  pad.  The  feet  and  legs  are  well  covered  up,  with  the 
addition,  if  necessary,  of  a  hot-water  bottle. 

Should  a  regular  head  bath  not  be  available,  an  ordinary 
washstand  basin  with  an  inverted  soap-dish  in  the  middle, 
and  capped  with  a  sponge,  will  suffice.  Comfort  in  position 
is  essential,  and  care  should  be  taken  to  avoid  haste  in 
rising  from  the  supine  position. 

By  means  of  the  head  bath  anaemic  headaches  are  often 
relieved  and  sexual  excitement  allayed.  Hughes  Bennett 
recommended  this  bath  in  delirium  tremens. 

Simple  head  bathing  for  a  very  few  minutes  is  often  of 
service  in  a  feverish  or  congestive  headache,  or  in  the 
headache  due  to  exposure  to  the  sun.  The  brow  and 
temples  are  sponged  with  cold  water  (18°  to  20°  C.)  for  two 
to  three  minutes,  the  patient  stooping  the  while  over  the 
basin  of  water. 

The  refreshing  effect  of  the  application  of  a  cold  sponge  or 
wet  napkin  to  the  posterior  auricular  region  is  well  known 
to  the  epicurean.  The  mental  obfuscation  induced  by  a 
good  dinner  and  the  accompanying  wine  is  thus  quickly 
removed,  hence  the  name  of  "the  alderman's  nerve" 
applied  to  the  posterior  auricular. 

The  headache  of  coryza  and  the  feeling  of  stuffiness  in 
the  nose  is  relieved  if  the  forehead  and  nose  be  sponged 
with  water  as  hot  as  can  be  borne  for  a  couple  of 
minutes. 

The  Leg  Bath.- — A  deeper  vessel  is  used  for  this  than 
in  the  foot  bath  (Fig.  29),  and  the  temperature  of  the  water 
will  vary  according  to  the  effect  desired. 

Hot  Leg  Bath.— Water  37°  to  45°  C.  for  ten  minutes,  fol- 
lowed by  tepid  sponging.  Mustard  may  be  added  to 
enhance  the  effect  if  there  be  no  contra-indication. 

Cold  Leg  Bath.— Temperature  10°  to  15°  C.  for  ten  minutes. 

The  Sweating  Leg  Bath. — 'The  bath  figured  above,  or  a  deep 
pail,  is  filled  to  within  3  inches  of  the  brim  with  water  at 
37°  to  38°  C.  The  patient  is  undressed  and  seated  on  a 
chair  covered  with  a  warm  flannel  pad,  with  his  legs  in  the 
bath.  He  is  completely  enveloped  in  a  blanket  previously 
warmed.  The  temperature  of  the  water  is  gradually  raised 
by  pouring  a  pint  of  boiling  water  into  the  bath  every  two 


84          MANUAL  OF  PHYSIO-THERAPEUTICS 

minutes — against  the  side  of  the  bath — a  similar  amount 
having  been  removed  in  advance.  The  temperature  should 
be  raised  as  high  as  the  patient  can  bear — about  45°  to  47°  C. 
— and  the  bath  continued  for  twenty  minutes.  The  patient 
will  perspire  profusely.  At  the  conclusion  he  is  dried 
lightly  with  warm  rough  towels  and  put  to  bed  between 
blankets,  sweating  being  encouraged  by  means  of  extra 
bed-clothes  and  hot  drinks. 


FIG.  31. — AN  IMPROVED  LEG  BATH. 

This  bath  is  an  extremely  handy,  inexpensive,  and  readily 
procured  sudorific  and  derivative  measure.  It  is  always 
of  service  where  diaphoresis  is  indicated  and  the  more 
elaborate  and  modern  methods  and  apparatus  are  not 
available.  It  is  useful  in.  suppressed  menstruation,  in 
dysmenorrhcea,  and  ovarian  congestion. 

The  Sitz  Bath. — The  ordinary  sitz  or  hip  bath  is  too 
well  known  to  need  much  detailed  description.  It  may  be 
made  of  porcelain,  metal,  or  wood  (Figs.  32,  33,  38). 

The  best  form  of  bath  known  at  present  is  probably  that 
of  the  Fischer  Kiefer  Co.,  which  is  made  of  plated  metal 
with  an  automatic  self-emptying  arrangement,  which 
maintains  the  water  at  a  constant  level.  The  male  sitz 
bath  usually  measures  20  inches  by  15  inches  in  breadth, 
and  has  a  nearly  straight  back.  The  female  sitz  bath  is 
usually  narrower  across  the  brim,  in  order  that  the  clothing 
of  the  patient  may  be  kept  out  of  the  water,  and  undress- 
ing be  avoided  if  so  desired.  A  hot-water  can  or  tub 
is  usually  placed  at  the  patient's  feet  and  a  wet  cloth 
around  his  head  while  the  bath  lasts  (Fig.  32).  The  water 


ON  THE  TAKING  OF  BATHS  85 

should  reach  to  the  level  of  the  patient's  umbilicus,  and 
about  5  or  6  gallons  are  usually  required. 

If  the  bath  is  of  anything  but  the  briefest  duration,  the 
patient  should  be  carefully  protected  from  cold  by  means 
of  a  blanket,  which  encloses  the  whole  bath,  with  his  feet 
and  legs. 

The  temperature  of  this  bath  will  vary  from  10°  to  45°  C., 
and  will  depend  on  whether  we  desire  it  to  be  cold  (10°  to 
20°),  tepid  (20°  to  30°),  warm  (30°  to  38°),  or  hot  (40°  to  45°). 
Many  people  will  be  unable  to  stand  anything  over  42°  C. 
The  duration  will  vary  from  two  to  thirty  minutes. 


FIG.  32. — SITZ  BATH,  WITH  FRICTION. 

Kellogg  considers  that  the  flexion  of  the  limbs  entailed 
by  this  bath  interferes  with  its  efficacy  by  restricting  the 
circulation. 

Modus  Operandi. — The  action  of  this  procedure  depends 
on  the  temperature  of  the  water  and  the  time  for  which  it 
is  kept  up.  The  pelvic  and  abdominal  viscera  are  reflexly 
stimulated:  a  cold  bath  of  any  duration  causes  them  to 
contract,  while  a  hot  bath  causes  dilatation.  In  the  reaction 


86          MANUAL  OF  PHYSIO -THERAPEUTICS 

after  a  cold  bath  dilatation  in  all  probability  ensues,  but 
the  effect  of  the  cold  lasts  for  some  time  and  induces  anaemia 
of  the  viscera. 

Intestinal  peristalsis  is  stimulated  by  brief  cold  baths, 
but  long-continued  cold  baths  lessen  peristalsis. 

Varieties  of  the  Sitz  Bath — 1.  Cold  SitzBath. — The  water 
should  cover  the  groins  and  no  more.  Wrapped  in  a 
blanket,  the  patient  remains  in  it  for  ten  minutes,  the 
attendant  rubbing  the  back  and  abdomen  if  at  all  chilly. 
It  is  not  necessary  to  undress  completely,  but  only  suffi- 
ciently to  keep  the  clothing  out  of  the  water.  The  patient 
is  carefully  dried,  and  should  take  a  short  sharp  walk  to 
get  thoroughly  warm. 

2.  Tepid.— 21-5°  for  ten  minutes,  with  a  little  cold  water 
run  in  at  the  finish. 

3.  Flowing. — Cold   water   is   kept  running   through   the 
sitz  bath  all  the  time.     Duration,  two  minutes,  or  less  if  the 
cold  be  felt  too  keenly. 

4.  Dipping. — The    bath    contains   cold    water    3   inches 
in  depth,  and  the  patient  keeps  moving  up  and  down  all 
the  time.     Grasping  the  sides,  he  rises  clear  of  the  water 
and  then  sits  down  again,  and  does  this  every  second  or 
two  for  two  minutes. 

5.  With  Water  as  Hot  as  can  be  Borne. — The  bath  is  full  of 
water  at  about  38°  C.,  and  a  foot  bath  of  the  same  tem- 
perature is  placed  in  front   of  it.     Hot   flannel  pads  are 
placed,  one  on  the  back  of  the  bath  and  the  other  floating  in 
the  water.     Completely  undressed,  the  patient  sits  down, 
and  is  enveloped  from  head  to  foot  in  warm  blankets.     A 
cold,  wet  cloth  is  wrapped  around  his  head.     A  minute  after, 
a  pint  of  boiling  water  is  poured  gently  against  the  side  of 
the  bath  (as  in  the  sweating  leg  bath),  removing  as  much 
beforehand  by  means  of  a  cup  or  the  overflow  pipe.     The 
wrappings  must  be   disturbed  as  little  as  possible.     Add 
boiling  water  thus  every  minute  until  the  bath  is  as  hot  as 
can  be  borne  (44°  to  40°  C.).     After  twenty  minutes  have 
elapsed  the  patient  gets  up  from  the  bath,  is  carefully  dried 
with  hot  towels,  and  put  in  bed  betAveen  blankets.     The 
room   in  Avhich  this  bath  is  given  should  be  comfortably 
warm. 


ON  THE  TAKING  OF  BATHS 


87 


6.  Hot  and  Cold  Alternate  by  Gradual  Transitions. — Begin 
with  38°  C.,  and  raise  the  temperature  as  high  as  can  be 
borne  (43°  to  46°  C.).  Then  slowly  reduce  as  before,  taking 
about  two  minutes  for  each  change,  and  ten  minutes  in  all 
for  the  bath.  The  patient's  clothing  is  entirely  removed. 


FIG.    ^3. — ASCENDING  DOUCHE  FITTING  FOE,  PILES  AND 
PRURITUS  ANI,  PROLAPSUS,  ETC. 

Temperature  varies  for  each  case. 

7.  Hot  and  Cold  Alternate  by  Sudden  Changes. — Two  sitz 
baths  are  used  side  by  side,  one  containing  water  at  18°  C., 
and  the  other  hot  water  at  42°  C.  The  patient  moves 
from  one  to  the  other  every  two  minutes,  beginning  with 
the  hot  and  ending  with  the  cold  water.  The  bath  is 
continued  for  eight  or  ten  minutes. 


88          MANUAL  OF  PHYSIO-THERAPEUTICS 

8.  Warm  Sitz  Bath  with  Cold  Affusion  to  the  Abdomen. — 
The  patient  is  seated  in  water  at  38°  C.,  with  the  bath  full 
to  the  overflow  pipe.     A  pint  of  cold  water  (18°  C.)  is  poured 
over  the  lower  part  of  the  abdomen  every  two  minutes 
from  a  height  of  a  foot  or  so.     The  surface  of  the  abdomen 
is  rubbed  all  the  time,  either  by  the  attendant  or  the  patient 
himself.     The  bath  concludes  with  cold  sponging  of  the 
parts,  and  lasts  for  ten  minutes. 

9.  With  Mustard. — This  bath  is  the  same  as  No.  5,  only 
a  tablespoonful  of  table  mustard  or  a  cupful  of  mustard 
bran  is  added  to  each  gallon  of  water. 

THERAPEUTIC  INDICATIONS. — Cold  sitz  baths  of  from  two 
to  five  minutes'  duration  are  indicated  in  various  abdominal 
and  pelvic  diseases  and  affections,  such  as  ovarian  and 
uterine  neuralgia,  chronic  prostatic  congestion,  and  bladder 
atony;  in  chronic  gastric  catarrh,  chronic  intestinal  catarrh, 
and  hepatic  congestion;  in  constipation,  amenorrhcea,  and 
sometimes  in  spermatorrhoea  and  impotence.  Although 
the  cerebral  activity  is  often  markedly  increased,  in  some 
cases  of  insomnia  sleep  is  induced  by  this  procedure. 

Care  must  be  taken  never  to  use  cold  sitz  baths  in  any 
acute  inflammatory  condition  of  the  abdominal  viscera  or 
in  cystitis. 

Prolonged  cold  sitz  baths  from  three  to  eight  minutes 
exsanguinate  the  intestinal"  surface,  and  are  useful  in  various 
diarrhoeas  and  dysentery,  in  piles  and  proctiiis,  chronic 
menorrhagia  and  pelvic  congestion  (especially  if  combined 
with  hot  vaginal  douches). 

Warm  sitz  baths  from  twenty  minutes  to  one  hour  in 
duration  have  a  sedative  and  anodyne  effect,  and  are  useful 
in  acute  and  chronic  inflammatory  conditions,  in  constipa- 
tion, and  the  ansemia  often  associated  with  it. 

The  hot  sitz  bath  is  useful  in  restoring  suspended  men- 
struation, in  vaginismus  and  ovarian  neuralgia.  In  renal 
colic,  neuralgia  of  the  testicles,  sciatica,  tenesmus,  and 
any  painful  non-inflammatory  affections  of  the  pelvic  or 
lower  abdominal  viscera  it  is  indeed  a  powerful  analgesic. 
The  mustard  sitz  bath  is  at  all  times  a  derivative,  and  it  is 
often  employed  effectually  in  amenorrhcea. 

The  cold  sitz  bath  produces  a  profound  effect  on  all  the 


ON  THE  TAKING  OF  BATHS 


89 


FIG.  34. — GENERAL  BATH  AND  DOUCHE  ROOM. 


FIG.  35. — SITZ  BATH,  XAUHEIM  BATH,  AND  PACKING  COUCH. 


90  MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  36. — THE  HALF  BATH  WITH'AFFUSION. 


FIG.  37. — THE  HALF  BATH  WITH  FRICTION. 


ON  THE  TAKING  OF  BATHS 


91 


FIG.  38.— THE  SITZ  BATH. 


FIG.  3D. — BACK  LAVING  OR  SPONGING. 


92          MANUAL  OF  PHYSIO-THERAPEUTICS 

bodily  functions.  There  is  lessened  activity  of  the  skin, 
"goose  flesh,"  contraction  of  the  cutaneous  vessels,  and 
slowing  of  the  pulse. 

A  hot  sitz  bath  acts  as  an  anodyne,  antispasmodic,  and 
derivative  measure.  The  pelvic  circulation  is  increased, 
and  blood  diverted  to  the  pelvic  viscera. 

The  Back  Laving. — The  patient,  partially  dressed,  or 
covered  with  a  blanket,  sits  across  a  sitz  bath  half  full  of 
cold  water,  while  the  attendant  with  a  sponge  laves  the 
entire  spine  for  five  minutes  with — 

1.  Cold  Water. — If  the  clothing  be  removed,  the  patient 
should  be  carefully  covered  up  in  front  by  means  of  a 
specially  made  blanket  (Fig.  39). 

2.  Tepid  to  Cold. — At  27°  C.  for  four  minutes,  and  cold 
for  one  minute. 

3.  Hot  and  Cold  Alternate. — The  water  is  run  gradually 
from  warm  (32°  C.)  down  to  cold,  and  then  up  again  to  as 
high  a  temperature  as  can  be  borne  (46°  to  47°  C.),  and  once 
more  down  to  cold.     The  back  is  laved  for  five  minutes  in  all. 

4.  Hot  and  Cold  Alternate,  with  Rapid  Changes  from  Hot 
to  Cold,  each  for  Half  a  Minute.— This  is  done  by  having  a 
couple  of  cans  or  buckets  side  by  side,  with  hot  and  cold 
water,  and  using  a  separate  sponge  for  each.     Duration,  five 
minutes  in  all. 

5.  With  Mustard. — A  breakfast-cupful  of  mustard  bran 
(or  a  tablespoonful  of  table  mustard)  is  used  to  each  quart 
of  water,  which  should  be  as  hot  as  the  patient  can  bear 
it.     Duration,  four  minutes,  or  less  if  felt  too  acutely.     The 
bath  is  finished  with  cold  water  for  fifteen  seconds. 

The  Back  Spouting— 1.  Cold.— A  jet  of  cold  water  is 
played  up  and  down  the  whole  length  of  the  patient's  back, 
the  patient  being  partially  undressed  and  seated  on  a  board 
placed  across  the  sitz  bath.  One  minute  will  suffice. 

2.  Warm  to  Cold. — Begin  at  32°  C.,  and  run  gradually 
down  in  the  course  of  a  minute  to  cold,  at  which  it  is  con- 
tinued for  two  minutes  or  more. 

3.  Hot  and  Cold  Alternate.— Hot  (45°  C.)  at  first  for  half 
a  minute,  then  cold  for  half  a  minute.     Keep  changing  from 
one  to  the  other  for  three  minutes,  and  then  conclude  with 
cold. 


ON  THE  TAKING  OF  BATHS 


93 


These  are  all  tonic  bracing  applications.  The  hot  and 
mustard  applications  are  best  suited  to  the  old,  and  patients 
with  feeble  circulation.  The  back  spouting  is  only  adapted 
to  the  more  vigorous  type  of  patients. 

The  Half  Bath.— An  ordinary  shallow  household  bath 
is  used,  about  half  full  of  water  from  20°  to  30°  C.,  accord- 
ing to  the  effect  we  desire  to  produce.  After  cooling  his 
head  with  water,  the  patient  enters  the  bath  and  sits  down 
so  as  to  be  about  half  immersed.  He  lowers  his  body  for 
a  moment  so  as  to  immerse  the  shoulders,  and  then  returns 
to  the  sitting  posture,  while  an  attendant  freely  douches 


FIG.  40. — MODERN  TYPE  OF  SET-IN  BATH. 


the  upper  portion  of  his  body.  He  again  lowers  himself 
into  the  semi-recumbent  position  while  the  attendant 
briskly  rubs  the  chest,  abdomen,  and  limbs  with  bare 
hands  or  friction  gloves  (Figs.  36,  37).  The  bath  is  then 
completed,  and  the  patient  wrapped  in  a  warm  sheet  and 
dried. 

This  bath  is  stimulating,  and  a  good  reaction  is  encouraged 
by  the  friction  movements ;  generally  speaking,  the  warmer 
the  temperature  of  the  water,  the  less  the  stimulating  effect 
of  the  bath.  The  quicker  the  reaction,  the  greater  is  the 
amount  of  heat  abstracted. 

This  bath  is   of   great    service  as   an   antipyretic,    but 


94  MANUAL  OF  PHYSIO-THERAPEUTICS 

should  not  be  used  for  more  than  a  very  short  period 
where  the  patient  is  weak  and  collapsed.  In  such 
cases  it  is  well  to  give  the  patients  a  warm  and  even 
stimulating  drink  immediately  before  the  bath  is 
administered. 

INDICATIONS.— Cool  baths  (22°  to  26°  C.)  of  three  or  four 
minutes'  duration  may  be  used  regularly  in  the  morning 
as  a  hygienic  measure  for  people  in  ordinary  health.  They 
may  be  combined  with  friction,  and  are  exceedingly  pleasant 
and  refreshing. 

In  diseases  of  digestive  character,  such  as  gastric  irrita- 
tion, or  atony,  or  hyperchlorhydria,  this  bath,  combined 
with  hot  and  cold  douching  to  the  abdomen,  is  exceedingly 
helpful  and  beneficial.  The  douching  can  be  carried  out 
by  the  patient  himself  by  means  of  a  tin  basin,  or  more 
efficiently  by  an  attendant. 

In  affections  of  the  spinal  cord,  etc.,  the  temperature  of 
the  water  should  be  from  28°  to  30°  C.  If  the  lesion  be  an 
irritative  one,  such  as  ataxic  paraplegia,  chorea  gravis,  or 
paralysis  agitans,  the  water  may  be  even  warmer  with 
advantage.  In  myelitis  and  other  paralytic  conditions  a 
brief  cool  bath  is  best. 

The  Use  of  the  Half  Bath  in  Typhoid  and  Other  Fevers.— 
Although  scarcely  within  the  scope  of  this  work,  it  may  be 
well  to  allude  briefly  to  the  extreme  value  of  the  cooling 
bath  in  typhoid,  as  advocated  by  Brand,  Barr,  and 
others. 

The  Plunge  Bath. — The  temperature  of  the  water  should 
be  cool  or  cold,  from  22°  down  to  15°  C.  The  duration, 
one  to  three  minutes.  The  bath  should  be  about  half  full, 
to  admit  of  the  patient  moving  and  splashing  freely  without 
upsetting  much  water.  This  bath  has  a  marked  stimu- 
lating effect  on  the  circulation  and  respiration.  The  brief 
application  of  the  cold  water  should  induce  a  quick  and 
good  reaction,  and  make  the  patient  feel  warm  and  comfort- 
able. This  effect  is  enhanced  if  the  patient  be  previously 
warmed  in  a  hot-air  bath  or  before  a  fire,  and  cold  water 
(15°  C.)  be  used.  While  thermolysis  is  somewhat  avoided 
by  this  procedure,  thermogenesis  is  proportionately  in- 
creased by  the  stimulus  of  the  cold. 


ON  THE  TAKING  OF  BATHS 


95 


THERAPEUTIC  INDICATIONS. — Cool  and  cold  plunge  baths 
are  of  service  when  general  stimulation  is  desired  without 
lowering  of  temperature.  While  primarily  stimulating  from 
the  bracing  effect  of  the  brief  exposure  to  cold  water,  they 
are  secondarily  sedative ;  not  a  few  people  who  suffer  from 
insomnia  find  that  sleep  is  induced  by  this  bath,  particularly 
if  they  do  not  dry  themselves  before  returning  to  bed. 

The  Full  Bath  (Cold),  or  Shallow  Bath.— This  is  now  an 
ordinary  household  bath,  6  or  7  feet  long  by  3  feet 
wide  (Fig.  40).  The  water  is  cold  (8°  to  12°  C.),  and 
should  be  kept  so  by  running  in  fresh  water  all  the  time. 
The  duration  is  very  brief- — not  more  than  sixty  seconds. 


FIG.  41. — PULSE-TRACING:  (a)  BEFORE,  (6)  AFTER  A  FULL 

BATH. 

The  patient,  having  previously  cooled  his  head  by  wetting 
it  under  the  tap  or  with  a  wet  towel,  completely  submerges 
the  body  once  or  twice,  and  then  gets  out.  The  bath  is 
intensely  stimulating  and  produces  a  brisk  reaction. 

The  respirations  are  much  quickened,  the  patient  often 
gasping;  the  circulation,  general  and  cutaneous,  is  strongly 
stimulated  (Fig.  41),  and  the  skin  markedly  reddened. 

This  bath  is  frequently  used  as  a  sequel  to  a  vapour  bath 
or  hot  pack,  but  is  only  so  employed  when  the  patient  is 
robust. 

If  followed  by  a  half  bath  at  16°  to  20°  C.,  this  procedure 
has  a  distinct  antipyretic  action.  The  cool  half  bath,  by 
way  of  comparison,  seems  tepid  to  the  patient. 


96 


MANUAL  OF  PHYSIO-THERAPEUTICS 


THERAPEUTIC  INDICATIONS. — 'Where  it  is  desired  to 
strongly  stimulate  metabolism  in  cases  of  gout,  syphilis,  and 
obesity,  and  also  in  certain  cases  of  tuberculous  disease. 

For  debilitated  and  exhausted  patients  it  is  unsuitable 
and  even  harmful. 

The  Drip  Sheet. 

The  patient  having  previously  been  moistened  or  wrapped 
in  a  damp  towel,  and  standing  in  a  warm  shallow  (|  inch 
deep)  foot  bath,  a  sheet  (2  by  3  yards)  folded  length- 


FIG.  42. — THE  DRIP  SHEET. 

wise  is  drawn  through  cold  water  and  wrapped  about  him 
in  the  following  manner :  The  attendant,  approaching  from 
the  front,  unfolds  a  portion  of  the  folded  border,  fixes  the 
free  edge  of  the  sheet  under  the  right  armpit  (Figs.  42,  43, 
44),  and  passes  it  across  the  patient's  chest,  below  the  left 
axilla,  and  around  the  back  and  over  the  right  shoulder, 
so  as  to  completely  envelop  him. 

The  patient's  entire  body  is  then  vigorously  chafed  and 


ON  THE  TAKING  OF  BATHS 


97 


smacked  through  the  sheet.  An  active  stimulus  is  provided 
by  the  cold,  and  also  by  the  manipulation.  The  skin  is 
reddened  and  the  circulation  rendered  increasingly  active ; 
the  respirations  are  quicker  and  deeper. 

The  duration  of  the  drip  sheet  varies.  The  attendant 
should  keep  up  the  rubbing  until  the  patient  feels  warm. 
The  effect  of  this  procedure  is  enhanced,  and  a  good  reaction 
more  quickly  attained,  if  the  patient  has  a  few  minutes' 
warming  in  the  hot-air  cabinet  or  Turkish  bath  before  the 
sheet  is  applied. 


FIG.  43. — THE  DRIP  SHEET: 
FURTHER  STAGE. 


FIG.  44. — PATIENT  COM- 
PLETELY ENVELOPED. 


The  use  of  the  shallow  warm  foot  bath  is  of  particular 
importance  when  the  patient  is  weak  or  sensitive.  On  a 
good  reaction  being  established,  he  is  thoroughly  dried 
and  allowed  to  rest  for  some  time  on  a  couch  or  bed  well 
covered.  As  a  rule  a  good  reaction  is  sooner  obtained  if 
cold  water  be  used,  rather  than  tepid  or  warm. 

Very  little  antipyretic  effect  is  produced  by  the  drip 
sheet,  but  if  it  is  desired  to  cause  heat  abstraction,  the 


98          MANUAL  OF  PHYSIO-THERAPEUTICS 

sheet  should  be  freely  rewetted  with  cold  water  and  the 
bath  somewhat  prolonged. 

This  application  may  be  varied  in  several  ways.  The 
sheet  may  be  wrung  out  of  cold  water  before  application, 
and  applied  merely  moist,  constituting  the  "cold  rub": 
given  in  this  way,  it  is  a  milder  and  less  stimulating  applica- 
tion; or  it  may  be  preceded  by  a  hot  sheet  wrung  out  of 
water  at  40°  C.,  and  applied  for  half  a  minute.  In  the 
case  of  delicate  and  bedridden  patients,  what  is  known  as 
the  partial  rub  may  be  employed.  A  small  sheet  is  used, 
and  each  limb  dealt  with  in  turn,  care  being  taken  to  keep 
the  rest  of  the  body  warm.  This  last  is  an  excellent  sub- 
stitute for  the  half  bath  in  febrile  conditions. 

GENERAL  INDICATIONS. — The  drip  sheet  is  a  general 
stimulant  and  invigorating  procedure,  improving  the  circula- 
tion and  increasing  metabolism.  It  is  of  service  in  catarrhal 
conditions  of  the  gastro-intestinal  tract,  feeble  circulation, 
and  defective  metabolism. 

Caution.- — It  should  not  be  employed  in  patients  who 
show  arterio-sclerosis,  in  exophthalmic  goitre,  in  the  highly 
nervous,  or  persons  suffering  from  skin  inflammations. 


CHAPTER  III 
DOUCHES,  WHIRLPOOL  BATH,  ETC. 

A  DOUCHE  consists  of  a  single  or  multiple  column  of  water 
directed  against  some  portion  of  the  body.  The  three  main 
factors  in  this  procedure  are  : 

1.  Temperature   of  the   water   employed,    which  ranges 
from  10°  to  40°  C. 

2.  The  pressure  of  the  water,  which  ranges  from  10  to 
60  pounds  per  square  inch,  but  is  usually  about  30  pounds. 
More  than  this  is  often  unpleasant  and  may  be  unsafe. 
The  water  is  usually  projected  under  pressure,  or  a  mechani- 
cal stimulus  may  similarly  be  obtained  by  allowing  it  to 
fall  from  a  height  on  to  the  patient. 

3.  A  third  factor  is  the  volume  of  the  douche,  or,  in 
other    words,     the     pressure     will     vary     with     the     size 
of    the    orifice   through    which    the    water    is    projected. 
The   orifice   is   commonly  about  |  inch  in  diameter,  but 
it   may  be  filiform;  or  in  the  descending  gravity  douche 
a    full    1|     inches     in     diameter.      The    pipe    of     supply 
should   be   at   least    14-  inches  in  diameter,  and  have  an 
independent  and  separate  connection  with   hot   and  cold 
water  supplies. 

With  the  douche  should  be  connected  a  reliable  pressure 
gauge  and  thermometer.  Where  it  is  proposed  to  use  the 
vapour  douche,  a  steam-pipe  with  suitable  nozzle  must  be 
also  available. 

The  best  connection  apparatus  are  those  of  Kellogg  and 
the  Fischer  Kiefer  Co.,  of  Zurich.  Whatever  appliance  is 
used,  it  is  in  the  first  degree  essential  that  accuracy  and 
precision  of  dosage,  as  regards  temperature  and  pressure, 
are  not  only  possible,  but  easy  to  obtain. 

The  chief  varieties  of  douche  are  the  following : 

99 


100        MANUAL  OF  PHYSIO  THERAPEUTICS 

The  horizontal  jet. 

The  percussion  douche. 

The  rain  douche,  horizontal  or  vertical. 

The  fan  douche. 

The  needle  bath. 

The  Scotch  douche. 

The  filiform  douche. 

Local  douches  may  be  applied  to  the  lungs,  liver,  or 
spleen  (that  is  to  say,  the  skin  surface  over  them),  to  the 
abdomen  or  perineum. 

Modus  Operandi.—The  douche  is  one  of  the  most  power- 
fully stimulating  procedures  in  the  range  of  hydrothera- 
peutics.  Its  actual  effects  will  depend  on  the  temperature 
of  the  water  employed,  its  pressure,  duration  of  the  applica- 
tion, form  and  size  of  the  stream,  the  region  to  which  it  is 
applied,  and  the  extent  of  its  application. 


FIG.  45. — HORIZONTAL  DOUCHE. 

By  the  use  of  the  douche  the  heart  is  markedly  stimulated, 
with  resultant  quickened  circulation,  and  the  flow  of  lymph 
is  likewise  accelerated,  as  in  general  massage.  A  rapid  and 
powerful  reaction  is  induced.  The  cold  douche  is  a  powerful 
tonic,  and  the  Scotch  douche  and  alternate  hot  and  cold 
douche  are  very  powerful  excitant  applications. 

The  Horizontal  Douche.— This  is  the  most  useful  and 
probably  most  commonly  employed  form  of  douche.  It 


DOUCHES 


101 


may  be  in  the  form  of  a  single  jet  (Fig.  45),  or  the  jet  may 
be  broken  and  spread  out  in  fan-like  fashion  (Fig.  52). 
The  usual  size  of  the  nozzle  is  \  inch  in  diameter.  The 
force  of  the  jet  may  be  varied  by  use  of  the  operator's 
finger  at  the  nozzle. 

Care  is  always  necessary  not  to  project  the  water  under 
too  great  pressure,  especially  in  the  case  of  nervous  subjects. 


FIG.  46. — KELLOGG'S  NOZZLE. 


The  Percussion  Douche. — This  is  a  special  form  of  douche, 
by  means  of  which  a  water  column  of  any  desired  form 
may  be  obtained,  from  a  widely  scattered  shower  of  large 
drops  to  a  fusillade  of  water  bullets,  which  Kellogg  likens 
to  the  discharge  of  a  Catling  gun  (see  shape  of  nozzle  in 
Fig.  46).  The  pressure  under  whicli  the  water  is  projected 
is  higher  than  in  the  ordinary  douche,  and  a  stinging  sensa- 
tion is  produced  as  the  water  strikes  the  patient's  skin 


FIG.  47. — THE  "  ROSE  "  FOR  RAIN  OR  SPRAY  DOUCHE. 

One  of  the  advantages  of  this  application  is  that  the 
powerful  stimulating  effect  of  the  percussion  allows  the 
use  of  water  of  a  higher  temperature  than  would  be  suitable 
in  the  ordinary  douche,  and  by  many  patients  who  are 
intolerant  of  cold  water  this  is  much  appreciated. 

The  Scotch  Douche.— This  consists  in  the  alternate 
application  of  the  hot  and  cold  horizontal  douche.  The 
hot  water  lasts  for  from  one  to  four  minutes,  and  the  cold 
is  continued  for  about  ten  to  thirty  seconds.  The  applica- 


102        MANUAL  OF  PHYSIO-THERAPEUTICS 

tion  may  be  general  or  local,  as  in  the  treatment  of  sciatica. 
The  derivative  effect  of  the  application  of  the  hot  water  is 
greatly  intensified  by  the  subsequent  cold  water. 

The  Rain  Douche. — This  is  a  common  bathroom  appli- 
ance. The  water  is  projected  through  a  watering  "rose," 
or  perforated  disc  of  varying  size,  falling  upon  the  patient 
in  a  number  of  fine  streams. 

The  pressure  of  the  water  is  lower  in  this  application,  and 
the  reaction  follows  more  slowly  than  after  the  horizontal  jet. 

This  bath  was  much  prescribed  by  Priessnitz,  and  Kellogg 
regards  it  as  an  indispensable  part  of  a  completely  equipped 
hydrotherapeutic  establishment. 


FIG.  48. — PULSE-TRACING:  (a)  BEFORE,  (b)  AFTER  A  SPRAY 
DOUCHE. 

Combination  Needle  and  Douche  Bath.— This  consists 
of  a  vertical  cage,  constructed  of  tiers  of  circular  tubing 
supported  by  uprights  and  pierced  with  innumerable  pin- 
holes,  through  which  the  douche  is  projected  upon  the 
patient  standing  within.  The  pipes  conveying  the  hot  and 
cold  water  meet  in  a  mixing  box,  in  which  a  thermometer 
enables  the  operator  to  regulate  the  temperature  to  any 
desired  degree.  This  bath  is  commonly  combined  with 
the  preceding. 

The  Filiform  Douche. — -In  this  the  jet  of  water  is  hori- 
zontal, and  issues  from  an  exceedingly  small  opening, 
capillaiy  in  character.  The  water  is  forced  under  great 
pressure,  and  becomes  a  cloud  a  short  distance  from  the 
apparatus.  This  douche  may  be  applied  for  any  time  up 


DOUCHES 


103 


to  ten  minutes,  and  is  strongly  counter-irritant  in  action. 
It  may,  indeed,  even  induce  bleeding. 

THERAPEUTIC  INDICATIONS  FOR  DOUCHES..— The  cold 
douche  is  a  tonic  procedure  of  the  highest  value;  it  is  both 
alterative  and  restorative.  Under  its  influence  "the 
individual  begins  to  live  a  more  vigorous  life,  physi- 
cally, mentally,  and  we  may  say  even  morally  "  (Kellogg). 


FIG.  49. — -THE  Aix  DOUCHE  WITH  Two  ATTENDANTS,  AS  AT 

Aix. 


It  is  of  value  in  most  forms  of  cardiac  disease,  in  rheu- 
matism, and  neuralgia.  Neurasthenia,  chlorosis,  and  all 
the  curable  forms  of  anemia,  are  markedly  benefited  by 
it,  as  also  are  various  dyspeptic  conditions  and  chronic 
alcoholism. 

It  should  not  be  used  in  acute  or  chronic  nephritis,  or  in 
badly  compensated  cardiac  disease. 


104        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  Scotch  douche  is  of  extreme  value  in  various  paretic 
conditions,  in  sciatica,  neuralgia,  gastralgia,  and  lumbago. 
The  cold  or  alternate  douches  are  also  useful  in  various 
sexual  disorders,  such  as  amenorrhcea,  dysmenorrhcea, 
sexual  neurasthenia,  and  impotence.  The  combined  needle 
and  rain  bath  is  a  morning  rouser  and  refresher  par  excel- 
lence. The  filiform  douche  is  indicated  wherever  counter- 
irritation  is  required,  as  in  sciatica,  lumbago,  and  chronic 
rheumatism. 

The  Aix  Douche,  or  Massage  Douche,  is  a  most  valuable 
balneological  agent,  and  is  extensively  used. 


FIG.  50. — PULSE-TRACING:  (a)  BEFORE,  (6)  AFTER  A  VICHY 
DOUCHE. 

The  patient  is  seated  on  a  wooden  stool,  or  reclines  on  a 
board,  and  a  continuous  needle  spray  is  directed  against 
the  spine,  while  massage  is  administered  by  one  or  more 
attendants  under  a  warm  douche,  conveyed  by  a  flexible 
tube  passing  over  the  shoulder  of  the  masseur  (Fig.  49), 
and  playing  between  his  Jiands.  This  may  be  followed 
by  a  local  hose  douche,  and  the  bath  terminates  with 
a  needle  spray,  warm  at  first,  and  graduated  slowly 
to  tepid,  cool,  or  cold,  according  to  the  requirements  of 
the  particular  case.  The  duration  of  the  bath  is  twenty 
minutes.  It  is  useful  in  a  variety  of  affections,  the  chief 
of  which  are  chronic  gout  and  the  gouty  state;  chronic 
rheumatic  arthritis,  lumbago,  and  sciatica;  arthritis 
deformans;  in  toxaemia  from  high  living  with  sedentary 


DOUCHES  105 

habits;  in  cases  of  brain  fag  from  too  assiduous  work;  in 
obesity ;  in  heart  disease  of  peripheral  origin ;  and  in  many 
other  disorders.  't  t 

The  Vichy  Massage  Douche  resembles  the  Aix  douche 
very  closely,  with  some  modification  of  procedure.  The 
patient  lies  in  a  recumbent  position  on  an  india-rubber  air 
mattress,  while  massage  is  administered  under  a  spray 
douche  projected  from  a  series  of  brackets  pierced  with 
pin-holes  suspended  over  the  table  (Fig.  51).  The  duration 


FIG.  51. --THE  VICHY  DOUCHE  WITH  THKEE  SPRAYS. 

of  the  bath  is  twenty  minutes,  and  it  terminates  with  a 
needle  spray.  A  preliminary  steam  bath  is  often  given,  and 
free  perspiration  induced  before  the  massage  is  started. 

The  Aix  Douche.— This  is  a  modification  of  the  Vichy 
douche,  in  that  the  patient  is  usually  sitting.  The  ap- 
paratus used  at  Aix  is  described  by  Forest ier  as  follows : 

1.  The  jumelle,  which  consists  of  a  couple  of  pipes,  one 
for  hot  water  and  one  for  cold,  entering  into  a  small  reservoir 
or  melangeur,  in  which  they  are  mixed.  From  this  reser- 


106        MANUAL  OF  PHYSIO-THERAPEUTICS 

voir,  which  is  provided  with  a  thermometer,  starts  an 
india-rubber  hose  with  a  bent  nozzle  held  by  the  masseur 
in  front  of  the  patient. 

2.  A  metal  box  (boite  de  melange),  which  is  fixed  about 
C  feet  from  the  ground  to  receive  the -;. mixture  of  hot  and 


FIG.  52. — THE  BROKEN  HORIZONTAL  JET  DOUCHE. 

cold  water,  and  connected  with  an  india-rubber  hose  fitted 
with  a  rose,  which  is  held  by  the  masseur  standing  behind 
the  patient.  The  first  apparatus  carries  the  water  coming 
from  the  upper  reservoir  at  a  high  pressure  (45  feet  above 
the  ground  floor,  20  feet  at  the  second  floor).  But  this 
pressure  has  little  importance,  the  object  being  to  have 


DOUCHES 


107 


a  not  too  strong  stream  of  water,  which  by  its  splashing 
would  only  inconvenience  the  masseurs  at  their  work. 

The  last  article  to  mention  is  the  specially  constructed 
low  chair  or  stool  with  side  arms  and  no  back  on  which  the 
patient  sits.  By  laying  a  wooden  board  on  it  this  stool 
can  at  will  be  turned  into  an  inclined  plane,  on  which  the 
patient  lies  face  downwards. 


FIG.  53. — THE  Aix  DOUCHE. 


Administration  of  the  Douche. — -The  first  part  of  the 
douche  massage  is  performed  after  the  old  Aix  system  in 
the  sitting  posture.  The  patient  sits  on  the  stool  above 
described,  and  the  two  masseurs  or  masseuses  massage  the 
limbs  or  upper  part  of  the  trunk;  as  they  rub  they  keep 


108        MANUAL  OF  PHYSIO-THERAPEUTICS 

the  jet  of  warm  water  pouring  on  the  part  of  the  body 
being  treated  at  the  moment.  The  hose  is  largely  mani- 
pulated by  the  masseurs'  knees  or  thigh,  which  they  can 
do  very  cleverly.  Thus  the  arms  remain  at  liberty.  The 
masseur  standing  behind  does  the  massage  of  the  neck, 
shoulders,  and  upper  part  of  the  trunk;  the  other,  standing 
in  front  of  the  patient,  carries  out  the  massage  of  the  upper 
and  lower  limbs. 


FIG.  54. — THE  HORIZONTAL  PERCUSSION  DOUCHE. 

As  regards  the  second  part  of  the  douche  massage,  the 
patient  is  kept  in  the  reclining  posture,  as  first  suggested 
by  Forestier  and  adopted  at  Bath.  The  wooden  board 
is  laid  on  or  against  the  stool,  and  the  patient  lies  on  his 
stomach.  This  enables  the  masseur  to  handle  to  the  best 
advantage  the  back  of  the  limb  (sciatic  nerve),  along  with 
the  hips  and  lumbar  region. 

Finally,  the  patient  stands  up,  and  while  one  masseur  is 


DOUCHES  109 

preparing  the  towels,  the  other  gives  him  a  simple  douche 
down.  The  patient  is  well  dried  off  and  wrapped  in  a 
flannel  dressing-gown  and  blanket,  placed  in  the  sedan 
chair  used,  and  carried  back  to  the  bedroom. 

Owing  to  the  great  skill  and  care  shown  at  Aix,  where 
this  douche  has  been  used  so  long,  it  is  given  with  perhaps 
less  fatigue,  if  not  better  results,  than  anywhere.  The 
nearest  imitation  in  this  country  is  probably  Bath. 

The  Scotch  Douche.  —  This  was  first  devised  by  the 
eighteenth-century  Edinburgh  physician  Cullen.  It  was 
prescribed  as  a  tonic  chiefly,  and  consists  in  a  warm  stream 
of  water  for  one  or  two  minutes,  and  then  a  sudden  cold 
stream  for  a  few  seconds.  It  was  first  called  the  Scotch 
douche  by  Dr.  Despine  of  Aix,  whose  grandfather  was 
appointed  Director  of  the  Aix  Baths  in  178.7 ;  he  had  studied 
under  Cullen  at  Edinburgh,  learning  there  the  value  of  the 
cold  douche.  He  therefore  named  it  the  douche  ecossais. 
It  is  valuable  in  the  later  stage  of  sciatica,  or,  indeed,  any 
considerable  neuritis. 

The  Whirlpool  Bath. 

The  principle  underlying  this  treatment  is  the  application 
of  what  is  known  in  France,  where  the  bath  was  first  used, 
as  eau  courante  or  anglice,  "rushing"  water,  rather  than 
running  water,  for  the  treatment  of  stiff  joints,  contractures, 
and  war  injuries  of  various  sorts. 

The  baths  first  employed  in  this  country  were  copied 
from  the  French  model,  in  which  hot  and  cold  water  supplies 
are  led  into  a  mixing  chamber,  whence  the  water  at  required 
temperature  passes  into  the  bath  through  a  number  of  jets. 

After  rushing  around  the  bath,  the  water  flows  through 
an  opening  near  the  top.  The  whirlpool  effect  is  thus 
produced  by  a  constantly  flowing  stream  of  rapidly  flowing 
water.  To  obtain  a  satisfactory  stream  a  pressure  of  at 
least  50  feet  is  needed,  and  the  water  consumption  is  heavy. 
To  obviate  this  disadvantage  a  bath  was  introduced  in 
which  the  whirlpool  was  produced  by  means  of  an  electri- 
cally driven  turbine  placed  under  a  grating  in  the  bottom 
of  the  bath.  A  small  quantity  of  water  only  is  admitted 


110         MANUAL  OF  PHYSIO-THERAPEUTICS 


- 

H 
•^ 

PQ 


DOUCHES  111 

from  time  to  time  in  order  to  maintain  the  temperature, 
while  a  corresponding  amount  is  allowed  to  flow  through 
the  waste  pipe.  A  very  small  quantity  of  water  is  thus 
required  only.  A  further  modification  has  been  added 
whereby  the  water  can  be  made  gaseous,  which  enhances 
the  effect  and  has  been  specially  useful  in  neuritis. 

Baths  are  made  of  various  types  and  sizes — some  for 
arm  or  legs,  and  a  very  large  one  in  which  not  only  one 
but  several  patients  can  sit  and  be  treated  at  the  same 
time.  The  period  of  immersion  is  usually  about  twenty 


FIG.  56. — THE  WHIRLPOOL  BATH. 

minutes.  Temperature  from  110°  F.  to  120°  F.,  or  as  hot 
as  can  be  borne  comfortably.  Before  immersion  of  the 
limb  the  water  is  kept  at  100°  F.,  and  then  gradually  raised 
to  the  limit  of  endurance.  Several  treatments  may  be 
necessary  before  so  high  a  temperature  as  120°  F.  can  be 
borne.  This  is  particularly  the  case  where  there  are  areas 
of  anaesthesia  and  defective  sense  of  heat  and  cold,  as 
severe  scalding  might  occur  without  the  patient  or  physician 
at  first  being  aware.  Shortly  after  immersion  the  skin 
becomes  flushed  and  red,  pain  is  relieved,  and  a  comfortable 
sensation  induced. 


112        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  tissues  become  more  supple,  and  movements  can  be 
made  which  were  previously  painful  or  impossible.  After 
the  bath  the  limb  is  found  to  be  in  a  condition  of  hyper semia, 
with  the  skin  red  and  hot — in  all  probability  with  the 
internal  temperature  raised,  as  after  diathermy  or  electro- 
penetration. 

There  is  usually  an  increase  in  bulk  varying  from  ^  to 
\  inch  in  circumference.  The  tissues  are  soft  and  relaxed, 
and  will  bear  massage  and  manipulations  which  before  the 
bath  would  have  been  painful. 

Thus  the  procedure  is  very  commonly  used  as  a  preliminary 
to  massage  treatment.  It  is  claimed  in  traumatic  affection 
at  any  rate  that  in  this  respect  the  whirlpool  bath  is  an 
improvement  on  radiant  heat;  that  is  to  say,  the  skin  is 
less  irritated  and  the  deeper  tissues  more  thoroughly 
penetrated. 

Adhesions  can  be  more  readily  broken  down.  A  further 
point  with  this  bath  is  that  it  is  not  only  a  bath,  but  a 
delicate  form  of  massage  in  itself,  so  that  cases  unfit  for 
manual  manipulation  can  be  treated  by  it  without  pain  or 
damage  of  any  sort  to  the  tissues. 

It  has  been  used  with  great  success  in  cases  where  the 
nerves  in  the  vicinity  of  a  wound  have  been  slightly  damaged 
but  not  destroyed,  and  where  ordinary  heat  and  manual 
massage  are  too  painful.  Also  in  the  referred  pain  after 
an  amputation  great  relief  has  been  given. 

A  complete  outfit  is  expensive,  but  a  bath  for  arm  or  leg 
does  not  cost  a  large  sum.  Messrs.  Shanks  of  Barrhead 
have  taken  a  great  interest  in  the  subject,  and  fitted  up 
a  "large  number  of  these  baths  all  over  the  country. 


CHAPTER  IV 

THE  TECHNIQUE  OF  COMPRESSES,  PACKS, 
POULTICES,  ETC. 

The   Wet  Compress. 

THE  wet  compress  (or  Umschlag  of  Priessnitz)  consists  of 
a  swansdown  or  linen  fabric  wrung  out  of  water  of  varying 
temperature  and  applied  to  the  surface  of  some  part  of  the 
body.  The  compress  is  usually  applied  with  a  covering 
of  some  dry  and,  for  choice,  rather  impermeable  material 
to  prevent  loss  of  heat  by  evaporation.  Unless  so  covered, 
a  warm  compress  will  rapidly  become  cold  and  any  com- 
press dry.  Flannel  does  best  as  a  covering,  rubber  fabrics 
being  too  impermeable,  and  as  a  rule  preventing  evaporation 
too  completely. 

The  action  of  a  cold  compress  is  somewhat  obscure.  It 
has  been  explained  from  the  point  of  view  of  the  osmotic 
pressure  of  the  tissues  and  tissue  fluids.  The  osmotic 
pressure  of  a  solution  may  be  said  to  be  the  pressure  which 
dissolved  substances  exert  on  the  molecular  surface  of  the  fluid 
in  the  endeavour  to  increase  the  latter.  This  pressure  may 
be  very  considerable.  In  health,  the  osmotic  pressure  of 
human  blood-serum  is  constant,  and  is  about  1\  atmospheres. 

Variations  of  osmotic  pressure  may  be  expressed  in 
another  way  by  stating  the  lowering  of  the  freezing-point 
of  the  solution  under  examination.  Blood-serum  has  a 
freezing-point  depression  of  0-56°  to  0-57°  C.  (briefly  ex- 
pressed as  A).  The  endeavour  on  the  part  of  the  body  to 
keep  this  pressure  at  a  constant  level  is  spoken  of  as  the 
"  isotonic  balance  "  of  the  blood  and  tissues. 

In  inflammatory  conditions  the  osmotic  pressure  is 
changed  and  the  isotonic  balance  lost.  In  order  to  under- 

113  8 


114        MANUAL  OF  PHYSIO-THERAPEUTICS 

stand  the  conditions  affecting  an  inflamed  area,  we  may 
analyze  such  a  simple  condition  as  a  boil.  In  this  the 
central  pustule  is  at  abnormally  high  osmotic  pressure, 
ranging  between  O6°  C.  and  0'8°  C.,  and  may  even  rise  to 
1-4°  C.  Passing  outwards,  one  comes  to  the  hypersemic 
zone,  in  which  the  pressure  is  still  too  high,  but  is  increas- 
ingly lower  the  farther  we  go  from  the  central  pustule. 
Outside  this  is  the  area  of  manifest  oedema,  which  has  a 
pressure  varying  from  about  0-75°  C.  close  to  the  hypersemic 
zone  to  0-56°  C.,  which  is  the  pressure  of  normal  tissues. 
The  importance  of  this  change  in  pressure  is  realized  when 
one  learns  that  the  volume  of  a  cell  diminishes  as  the 
osmotic  pressure  of  the  fluid  in  which  the  cell  is  suspended 
is  raised  above  that  of  the  cell  itself.  Thus  a  red  blood- 
corpuscle  loses  about  one-quarter  of  its  volume  when  sus- 
pended in  a  1-5  per  cent,  solution  of  sodium  chloride 
(A  equals  -0-9°  C.)  compared  with  a  cell  suspended  in 
0-9  per  cent,  solution  of  sodium  chloride  (A  equals 
-  0-56°  C.).  Next,  as  is  well  known,  the  structure  of  a  cell 
is  materially  altered  by  suspension  in  a  fluid  of  higher 
osmotic  pressure  than  the  cell  itself.  Red  cells  lose  their 
disc  shape  and  become  spherical  when  kept  in  1-5  per  cent, 
solution  of  sodium  chloride.  Correspondingly,  the  function 
of  a  cell  suffers  when  the  isotonic  balance  is  lost.  This 
can  be  measured  by  watching  the  phagocytic  power  of 
leucocytes  suspended  in  a  saline  solution  of  varying 
strengths.  Clinically  it  is  found  that  when  the  osmotic 
pressure  of  a  part  is  raised,  the  part  has  undergone  an 
injury,  and  an  inflammatory  reaction  results. 

Isotonic  solutions  may  be  injected  into  the  tissues  with- 
out any  disturbance  of  a  pathological  nature,  but  pain 
invariably  results  if  the  solutions  be  hyper-isotonic.  This 
statement  does  not  apply,  of  course,  to  substances  which 
are  eschar  otic,  or  possess  corrosive  action  on  the  tissues 
with  which  they  are  brought  into  contact. 

The  osmotic  pressure  of  the  tissue  fluids  thus  plays  an 
important  part  in  the  process  of  inflammation.  The 
Priessnitz  application  causes  a  reactive  hyperfiemia,  and 
thus  tends  to  re-establish  the  balance  of  osmotic  pressure. 
Schade  considers  that  while  the  compress  possesses  no 


THE  TECHNIQUE  OF  COMPRESSES  115 

special  action  on  the  area  of  hyper semia — i.e.,  the  pustule 
and  its  immediate  vicinity — it  yet  converts  the  local  anaemia 
of  the  cedematous  zone  into  a  local  hypersemia.  The  result 
of  the  increased  circulation  through  this  zone  is  to  heighten 
the  lymph  circulation  centrifugally,  thus  getting  rid  of  the 
products  of  inflammation  rapidly  or  rendering  them  harm- 
less by  neutralization  with  the  various  substances  in  the 
lymph  or  serum. 

Hot  compresses  just  covering  the  acutely  inflamed  area 
rather  increase  the  pain,  while  those  reaching  over  the  whole 
of  the  area  affected  allay  pain  rapidly;  further,  ring-shaped 
fomentations  just  covering  the  area  surrounding  the  central 
inflammatory  area  also  rapidly  allay  pain. 

The  duration  of  a  compress  will  depend  on  the  effect 
desired.  Generally  speaking,  cold  compresses  are  renewed 
as  soon  as  they  become  warm,  and  hot  compresses  as  soon 
as  they  become  cool.  If  cold  compresses  be  left  on  until 
they  become  warm,  they  act  as  poultices  and  stimulate 
inflammatory  changes.  Compresses  dry  more  rapidly  on 
patients  with  brisk  circulations  and  hot  dry  skins  than  in 
those  with  feeble  circulation  and  who  are  in  an  asthenic 
or  cachectic  condition.  A  maximum  stimulating  effect 
may  be  obtained  when  hot  and  cold  compresses  are  applied 
alternately  to  any  part  of  the  body;  the  circulation  in  the 
part  is  increased  and  the  local  metabolism  markedly 
stimulated. 

THERAPEUTIC  INDICATIONS..— Cooling  compresses  are 
useful  in  all  local  pathological  conditions  of  an  inflam- 
matory nature,  and  aid  in  the  removal  of  hypersemia  or 
congestion  and  in  the  relief  of  pain. 

Warm  compresses  promote  suppuration  and  increase 
local  tissue  changes  and  the  absorption  of  morbid  products. 
They  have  a  local  antispasmodic  action,  and  often  relieve 
the  pain  of  neuralgia,  rheumatic  joint  pains,  etc. 

The  Various  Compresses  in  Use. 

The  Head  Compress. — This  is  a  well-known  application, 
and  one  of  great  service  in  various  congestive  conditions  of 
the  brain  and  meninges.  The  compress  is  applied  either 


116        MANUAL  OF  PHYSIO -THERAPEUTICS 

to  the  top  or  the  back  of  the  head,  and  in  the  latter  case 
the  back  of  the  neck  is  included  in  the  application.  If 
necessary,  the  whole  face  and  scalp  may  be  treated  together. 
It  must  be  borne  in  mind  that  a  cold  application  to  the  fore- 
head will  cause  collateral  hypersemia  of  the  brain,  while  one 
over  the  jugular  region  will  tend  to  cerebral  anaemia.  A  brief 
hot  compress  will  act  in  the  same  way.  Headaches  of  a 
neuralgic  character  are  often  relieved  by  this  compress. 
In  febrile  and  congestive  headaches  cold  compresses  afford 
most  relief.  The  head  should  be  carefully  dried  after  the 
compress  has  been  removed  (Fig.  57). 


FIG.  57. — HEAD  COMPRESS. 

Throat  Compresses. — These  are  very  commonly  employed 
domestically,  but  are  very  seldom  correctly  applied,  for 
the  usual  method  is  to  fold  a  handkerchief  into  a  narrow 
bandage  and  then  wind  it  round  the  neck  like  a  collar 
or  muffler.  So  applied,  it  rapidly  becomes  useless,  for  it 
is  soon  displaced  from  its  original  position  by  the  patient's 
movements,  and  air  is  allowed  to  enter.  The  proper  mode 
of  application  varies  with  the  condition  to  be  dealt  with 
(Fig.  58).  In  any  tracheal  or  laryngeal  trouble,  one  end 
of  the  bandage  should  be  wetted  and  covered  with  the 
other,  which  is  dry,  to  delay  evaporation;  or  a  wetted 
linen  handkerchief  should  be  applied  and  covered  with 
another,  preferably  of  silk,  and  larger  in  size  than  the 
under  one. 


THE  TECHNIQUE  OF  COMPRESSES 


117 


In  affections  of  the  tonsil  and  pharynx  the  application 
should  be  made  as  follows : 

A  piece  of  swansdown  calico,  long  enough  to  reach  from 
ear  to  ear  passing  underneath  the  chin,  is  folded  into  a 


FIG.  58. — THROAT  COMPRESS. 


four-layer  compress.  A  bandage  of  flannel  8  inches  by 
24  inches,  provided  with  a  slit  for  either  ear,  is  also  made ; 
these  are  fitted  by  actual  measurement  to  each  patient. 
The  calico  compress  is  now  wrung  out  of  water  at  15°  C.,  and 


FIG.  59. — THE  KELLOGG 
COMPRESS. 


FIG.  60. — COMPRESS  FOR  TONSILS 
AND  PHARYNX. 


laid  on  the  flannel  bandage  which  is  to  act  as  a  cover. 
The  wet  compress  being  placed  under  the  chin,  the  flannel 
bandage  is  now  unrolled  from  the  top  of  the  head,  on  the 
right,  the  ear  being  allowed  to  come  through  the  slit,  and 


118       MANUAL  OF  PHYSIO-THERAPEUTICS 

then  carried  underneath  the  chin  and  up  the  left  side 
(Fig.  60).  The  whole  compress  is  secured  by  means  of 
safety-pins,  care  being  taken  that  while  it  is  sufficiently 
tight  it  is  not  uncomfortably  so.  A  hot  compress  applied 
for  twenty  minutes,  and  then  followed  by  a  cool  one,  will 
do  good  in  many  throat  inflammations.  If  suppuration 
has  started,  as,  for  instance,  in  Ludwig's  angina,  the  hot 
compress  will  encourage  the  suppuration  and  tend  to  bring 


FIG.  61. — CHEST  COMPRESS. 

it  to  the  surface.  In  early  inflammatory  conditions  a  cold 
compress  will  often  go  far  to  subdue  and  check  the  in- 
flammation. 

The  Chest  Compress. — A  pad  of  towelling  or  swansdown 
calico,  eight  folds  thick,  is  wrung  out  of  cold  water  (iced  if 
desired)  and  applied  to  the  chest  for  twenty  minutes.  This 
is  covered  by  a  flannel  cross-binder,  which  passes  over  the 
patient's  shoulders  and  is  finally  fixed  by  a  tape  (Fig.  61). 


THE  TECHNIQUE  OF  COMPRESSES  119 

After  the  application  is  completed,  the  patient  is  carefully 
dried  and  rubbed  with  a  rough  towel.  In  pleurisy  of  a  dry 
and  painful  character,  this  compress  is  often  very  soothing 
to  the  patient ;  it  is  also  helpful  in  pericarditis  and  cardiac 
excitement.  In  all  cases  of  haemoptysis  it  is  a  valued  and 
serviceable  application.  Care  must  be  taken,  however,  not 
to  employ  it  in  cases  where  there  is  presumably  marked 
fatty  change  in  the  myocardium  associated  with  cyanosis, 
pulse  irregularity,  and  restlessness  on  the  part  of  the  patient 
(Kellogg). 


FlG.    62.  -  COMPKESS    FOB 


Cooling  Trunk  Compress.—  A  small  blanket,  no  broader 
than  will  reach  from  armpit  to  hip,  is  spread  across  the  bed, 
with  a  waterproof  sheet  of  like  size  beneath.  Upon  these 
is  laid  a  cotton  sheet  wrung  out  of  cold  water,  six  to  eight 
folds  thick,  of  nearly  the  same  breadth,  long  enough  to 
embrace  the  trunk  with  the  arms  excluded,  and  well  over- 
lapped in  front.  On  this  the  patient  lies  down  (Fig.  62), 
and  the  sheet  is  brought  round  and  tucked  tightly  under- 
neath the  flanks,  each  side  in  turn,  the  blanket  in  like 
manner,  and  the  waterproof  over  all.  A  hot-water  bottle 


120       MANUAL  OF  PHYSIO-THERAPEUTICS 

to  the  feet  and  a  cold  cloth  to  the  head  are  then  applied, 
and  the  patient's  lower  extremities  warmly  covered  up. 

This  application  exercises  a  markedly  antipyretic  effect, 
especially  if  frequently  renewed.  In  febrile  conditions  in 
which  drugs  seem  to  have  very  little  effect  on  the  pyrexia, 
this  application  will  frequently  bring  the  temperature  down 
several  degrees  in  a  few  hours. 

Most  patients  say  they  find  the  compress  very  comforting, 
and,  indeed,  it  is  a  most  convenient  and  valuable  therapeutic 
agent.  In  the  feverishness  of  children  due  to  some  gastric 
disturbance  it  is  especially  valuable,  and  the  writer  has 
found  it  of  service  in  acute  pneumonia. 

Although  the  antipyretic  action  is  enhanced  by  frequent 
renewal,  in  many  cases  it  may  be  left  on  for  four  or  five 
hours,  or  even  all  night,  without  changing.  Hyper  semia 
is  induced  on  the  surface  of  the  abdomen,  and  sleep  is 
encouraged  by  the  resultant  cerebral  anaemia. 


FIG.  63. — JOINT  COMPRESS. 

The  Abdominal  Bandage  (or  Neptune's  Girdle).— This  is  a 

piece  of  swansdown  calico,  3  feet  long  by  8  inches  to  10  inches 
wide.  A  length  sufficient  to  go  one  and  a  half  times  round 
the  patient's  abdomen  is  immersed  in  water,  wrung  out, 
and  wrapped  round  the  part.  The  dry  portion  is  then 
folded  over  the  wet,  so  as  to  prevent  undue  evaporation, 
and  may  be  further  covered  by  a  waterproof  cloth  of  some 
sort,  the  whole  application  being  secured  by  means  of 
tapes. 

This  bandage  can  be  worn  quite  well  whilst  the  patient, 
if  a  man,  goes  about  his  ordinary  daily  occupation,  but 
is  inconvenient  for  women  owing  to  the  corset.  It  is  an 
application  of  some  value  in  various  digestive  disorders, 


THE  TECHNIQUE  OF  COMPRESSES  121 

and  is  generally  of  a  soothing  nature,  though  nervous, 
irritable  subjects  often  dislike  it,  and  are  kept  awake  at 
night  by  it. 

Circular  Joint  Compresses. — These  are  made  of  strips  of 
swansdown,  18  inches  by  6  inches,  wrung  out  of  water 
and  applied  to  the  joint  to  be  treated,  covered  with  flannel 
or  waterproof.  They  are  useful  in  various  rheumatic  joint 
affections  (Fig.  68). 


FIG.  64. — ELECTRO-THERMAL 
COMPRESS. 


FIG.  65. — THE  COM- 
PRESSES APPLIED. 


The  Electrothermal  Compress  (or  Electric  Thermophore). 

— This  was  invented  by  Cerruti,  and  has  for  a  number  of 
years  been  in  use  in  Italy,  especially  in  the  hospitals  at 
Turin.  The  apparatus  is  really  a  compress  consisting  of 
light,  flexible,  and  incombustible  pads,  containing  electrical 
heating  apparatus  in  the  form  of  threads  of  asbestos,  around 
which  are  wound  fine  coils  of  resistance  wire  (Fig.  64). 


122        MANUAL  OF  PHYSIO-THERAPEUTICS 

These  threads  are  arranged  in  spirals  between  the  folds  of 
the  compress,  are  perfectly  insulated,  and  are  attached  at 
one  end  of  the  pad  to  thicker  wires  which  can  be  connected 
with  the  ordinary  electric  supply,  so  that  when  the  current 
is  turned  on  the  compress  is  heated  uniformly  throughout. 
The  amount  of  current  passing  is  regulated  by  means  of 
a  small  rheostat,  and  any  desired  temperature  up  to  about 
150°  C.  can  be  arranged  for.  There  is  a  removable  outside 
cover  for  each  compress,  which  can  be  periodically  cleaned. 
These  compresses  are  extremely  convenient  and  inex- 
pensive, but,  of  course,  can  only  be  used  in  houses  where 
the  electric  current  is  laid  on.  Placed  in  contact  with  the 
skin,  they  are  an  excellent  medium  for  the  application  of 
dry  heat ;  while  by  inserting  a  piece  of  damp  cloth  between 
the  compress  and  the  skin,  a  poultice  is  formed  which  can 
be  maintained  at  any  desired  temperature  for  an  indefinite 
length  of  time. 

The  Wet  Pack. 

This  is  applied  in  the  following  manner :  A  blanket 
2|  yards  square  is  placed  on  a  suitable  couch  or  stretcher 
bed,  and  upon  this  is  laid  a  coarse  linen  sheet  wrung  out  of 
water  at  16°  to  18°  C. 

The  patient,  around  whose  head  a  cool  compress  has  been 
arranged,  now  lies  down  on  the  sheet,  which  is  carefully 
and  smoothly  wrapped  about  him  in  the  following  manner : 
His  arms  are  raised  above  his  head,  and  one  half  of  the 
sheet  is  drawn  across  his  body,  its  upper  portion  tucked 
alongside  the  trunk  and  the  lower  between  the  lower  limbs. 
The  arms  are  brought  down  to  the  side  of  the  body  (Fig.  66), 
the  other  half  of  the  sheet  being  arranged  so  as  to  include 
them,  and  its  border  tucked  in  along  the  opposite  side 
beneath  the  arms  and  between  the  legs  in  such  a  manner 
that  the  two  skin  surfaces  do  not  come  into  contact.  The 
blanket  is  then  brought  together  at  all  points,  particular 
care  being  taken  to  cover  in  the  neck  and  shoulders  (Fig.  67). 

The  blanket  is  usually  equal  to  one  and  a  half  times  the  cir- 
cumference of  the  patient's  trunk,  and  serves  to  keep  in  the 
heat.  It  is  necessary  to  wrap  it  pretty  firmly  round  the 
patient  and  to  restrict  movements  of  the  limbs;  at  the  same 


123 

time  we  must  avoid  rendering  him  uncomfortable  or  giving 
him  pain.  The  feet  should  be  kept  warm  by  means  of  a 
hot- water  bottle  or  the  previous  application  of  friction. 


FIG.  67. — THE  WET]  PACK  COMPLETE. 


Action. — The  whole  body  surface  is  at  first  markedly 
stimulated  by  the  cold  sheet,  and  quickened  heart  action 
and  respiration  result.  Usually  the  sense  of  cold  disappears 
in  about  a  quarter  of  an  hour,  and  the  patient  becomes 


124        MANUAL  OF  PHYSIO -THERAPEUTICS 

warm  and  comfortable.  The  peripheral  vessels  dilate,  the 
pulse  slows,  and  the  patient  feels  drowsy,  often  falling 
asleep.  Later  perspiration  may  take  place,  depending  on 
the  duration  of  the  pack,  which  will  vary  according  to  the 
effect  we  desire  to  produce.  If  the  pack  be  changed 
frequently  a  marked  antipyretic  effect  is  obtained.  The 
warm  reaction  is  slower  each  time  the  pack  is  repeated. 


The  Dry  Pack. 

This  application  is  similar  to  the  wet  pack,  only  the  wet 
sheet  is  omitted  and  a  soft,  thin  blanket  or  flannel  sheet  is 
used  in  its  place,  covered  on  the  outside  with  a  thick  blanket. 
Indeed,  very  often  merely  a  single  thick  blanket  is  employed. 
The  patient  is  very  completely  enveloped,  and  a  hot-water 
bottle  placed  at  the  feet  (Fig.  68). 


FIG.  68.— THE  DRY  PACK. 


Reddening  of  the  skin  is  rapidly  induced  by  the  irritation 
of  the  blanket,  and  the  body  soon  becomes  warm.  Perspira- 
tion appears  with  a  rapidity  which  varies  with  the  indi- 
vidual— on  an  average  in  one  and  a  half  hours,  and  sooner 
than  in  the  wet  pack.  The  body  temperature  rises,  the 
tongue  becomes  dry,  the  pulse  and  respiration  quicken, 
while  the  head  feels  somewhat  full  and  congested.  Con- 
siderable discomfort  is  experienced  by  the  patient  until 
perspiration  is  actually  established.  The  onset  of  perspira- 
tion may  be  hastened  if  certain  preliminary  measures  be 
taken.  One  method  is  to  place  the  patient  in  a  hot  full 
bath  (40°  C.)  for  ten  minutes  before  applying  the  pack. 
This  is  useful  when  the  patient  is  suffering  from  chronic 
granular  kidneys  associated  with  high  blood-pressure. 
Another  method  is  to  get  the  patient  to  put  on  very  warm 
clothing  and  engage  himself  in  active  muscular  exertion, 


THE  TECHNIQUE  OF  COMPRESSES 


125 


such  as  swinging  Indian  clubs,  for  ten  minutes  or  so,  and 
then  put  him  in  the  pack.  The  pack  may  also  be  made 
more  active  arid  efficient  if  the  patient  lies  on  an  electric 
sweating  mattress  (Fig.  69),  in  which  heat  is  generated  by 
the  resistance  of  thin  conducting  wires. 

While  perspiration  is  going  on,  cold  water  should  be  freely 
drunk,  and  on  the  conclusion  of  the  pack  the  patient  should 
be  well  lathered  down  and  given  a  cold  spray  douche. 

Needless  to  say,  such  a  method  of  inducing  diaphoresis 
is  much  more  clumsy  and  tedious  than  the  hot-air  or  electric- 
light  bath;  but  blankets  are  often  available  where  these 
latter  luxuries  are  not  to  be  had. 


FIG.  69. — ELECTKIC  SWEATING  MATTRESS. 


THERAPEUTIC  INDICATIONS. — Metabolism  is  generally 
stimulated  by  these  packs,  but  if  often  repeated  they  are 
very  depressing  and  enervating,  and  are  contra-indicated 
if  the  patient  has  a  weak  heart.  They  are  indicated  in  any 
acute  or  chronic  toxaemia  in  which  the  establishment  of 
diaphoresis  is  desirable. 

In  febrile  conditions,  the  antipyretic  effect  of  the  wet 
pack  may  be  of  great  service.  Too  prolonged  application  or 
too  often  repeated  packs  will  cause  some  cardiac  depression, 
and  care  is  therefore  needed  in  this  respect.  Provided 
there  be  no  marked  cardiac  asthenia,  however,  in  some 
cases  of  hyperpyrexia  as  many  as  a  dozen  packs  may  be 


126        MANUAL  OF  PHYSIO-THERAPEUTICS 

given.  In  diphtheria  this  pack  is  of  especial  use,  combined, 
of  course,  with  the  usual  antitoxin  treatment. 

Other  conditions  benefited  in  a  varying  degree  are: 
Neuralgia,  chorea,  exophthalmic  goitre,  muscular  and 
articular  rheumatism,  and  rheumatoid  arthritis. 

For  patients  who  are  unusually  nervous  in  disposition, 
and  resent  the  complete  wrapping  up  and  restriction  of 
movement,  partial  packs  may  be  employed,  which,  while 
less  powerful,  are  efficient  for  soothing  and  hypnotic 
purposes. 

Fomentations  and  Poultices. 

Fomentations  and  poultices  are  simply  local  baths  to  the 
skin.  If  there  be  an  inflammatory  condition  of  skin  or 
structures  covered  by  it,  these  applications  are  a  convenient 
and  efficacious  means  of  employing  warmth  and  moisture 
in  the  treatment,  relieving  the  vessels,  increasing  the 
collateral  circulation,  and  so  relieving  the  local  circulation 
and  pain.  Thus  applied  at  the  commencement  of  inflam- 
mation, they  often  summarily  check  it,  abort  threatening 
abscesses,  and  prevent  the  formation  of  pus.  Acne  indurata 
and  herpes  labialis  may  be  much  restricted  by  the  applica- 
tion of  fomentations.  Discrimination  in  their  employment 
is  needful,  for  conditions  such  as  impetigo  contagiosa  are 
fostered  and  made  worse  by  such  applications. 

Again,  if  an  abscess  has  actually  formed,  the  repeated 
application  of  hot  fomentations  serves  to  "bring  it  to  a 
head,"  as  the  vulgar  phrase  goes,  helps  the  expulsion  of 
the  pus  without  the  aid  of  the  surgeon's  knife  (though  this 
may  be  often  a  shorter  and  more  aesthetic  cure),  and  prevents 
the  diffusion  of  the  inflammation. 

To  be  efficacious,  a  poultice  or  fomentation  must  be  hot 
—indeed,  as  hot  as  can  be  borne — and  must  be  frequently 
changed,  at  least  every  two  hours. 

If  the  object  of  the  poultice  be  to  hasten  an  abscess 
bursting,  it  should  be  large  and  ample;  but  when  the 
abscess  has  burst,  a  small  poultice  or  fomentation  about 
the  size  of  the  aperture  should  be  used,  or  the  surrounding 
skin  will  become  sodden  and  irritated  from  the  repeated 
application. 


Apart  from  the  soothing  local  effect  of  fomentations  on 
inflamed  tissues,  they  have  a  similar  action  on  deep-seated 
and  more  or  less  remote  parts  (vide  supra).  Thus  large 
hot  poultices  are  of  great  service  in  pleuiisy,  pneumonia, 
bronchitis,  pericarditis,  and  peritonitis.  In  dealing  with 
pneumonia,  caution  is  necessary  not  to  cause  additional 
respiratory  embarrassment  by  using  poultices,  especially 
for  children.  A  jacket  of  cotton-wool  or  gamgee  sprinkled 
with  turpentine  or  camphor  liniment  may  be  preferable 
in  such  cases.  The  jacket  poultice  for  children  has  fallen 
somewhat  into  desuetude. 

In  peritonitis,  too,  a  poultice  should  not  be  thick  and 
heavy,  or  the  pain  may  be  made  worse.  Poultices  are 
useful  in  acute  rheumatism,  sciatica,  pleurodynia,  and  in 
various  rheumatic  pains  and  acute  lumbago.  In  this  last 
condition  the  poultice  should  be  large,  thick,  and  very  hot; 
it  should  be  changed  about  every  thirty  minutes,  and  may 
be  kept  up  for  three  hours  if  necessary. 

In  changing  poultices,  the  fresh  one  should  be  ready  in 
hand  while  the  cooling  one  is  removed,  so  as  to  avoid 
chilling  the  skin. 

Fomentations  are  usually  composed  of  several  thicknesses 
of  flannel  wrung  out  of  boiling  water.  They  are  less  weighty 
than  poultices,  and  less  messy  and  septic.  The  water  is 
wrung  out  of  the  flannel  by  means  of  a  wringer  made  of 
stout  huckaback  towelling  attached  to  two  sticks  (portions 
of  a  broom-handle  do  well).  The  flannel,  after  immersion 
in  boiling  water,  is  placed  in  the  wringer,  which  is  then 
firmly  twisted  round  the  flannel  until  the  water  is  squeezed 
out.  The  operator  who  manipulates  the  sticks  thus  avoids 
scalding  his  hands,  though  the  water  may  be  very  hot. 
The  heating  may  also  be  conveniently  done  by  steam,  and 
this  is,  of  course,  always  available  in  a  properly  equipped 
bathing  establishment.  Having  been  exposed  to  the  steam, 
the  fomentation  is  run  through  a  roller  to  remove  any 
excess  of  moisture.  Until  actually  applied  to  the  patient, 
the  fomentation  is  kept  tightly  rolled  up  in  a  towel,  by 
grasping  the  loose  ends  of  which  a  final  squeeze  can  be 
given  to  extract  moisture.  The  proper  temperature  of  the 
application  is  gauged  by  the  back  of  the  attendant's  hand. 


128        MANUAL  OF  PHYSIO-THERAPEUTICS 

These  pads  are  made  in  two  sizes,  one  11  inches  by 
22  inches,  and  a  larger  22  inches  square.  They  are  about 
|  inch  thick  and  quilted.  When  applied  they  only  contain 
water  which  is  actually  absorbed  by  the  material;  they 
should  be  covered  at  once  by  some  mackintosh  material, 
and  frequently  changed,  as  they  cool  rapidly.  When  finally 
removed,  the  skin  of  the  patient  should  be  wiped  dry  and 
covered  with  a  layer  of  flannel  or  cotton-wool  to  prevent 
a  chill  being  taken. 

Such  hot  fomentations  are  most  useful  in  various  colics — 
renal,  biliary,  or  gastro-intestinal. 

A  hot  pad  may  be  alternated  with  a  cold  pad  in  certain 
conditions,  as  follows:  The  hot  pad  is  applied  for  five 
minutes,  and  then  a  piece  of  soft  calico  towelling  wrung 
out  of  cold  water  is  laid  over  the  part,  being  kept  on  for 
five  minutes  or  more,  when  the  hot  pad  is  once  more  applied 
to  the  surface.  Such  applications  are  useful  in  gastric  and 
gastro-intestinal  catarrh. 

Fomentations  may  also  be  medicated  in  various  ways, 
the  most  common  being  the  application  of  20  to  30  drops 
of  turpentine  oil,  constituting  "the  turpentine  stupe." 

Poultices  are  made  of  various  substances — bread,  linseed 
meal,  oatmeal,  or  starch.  Each  has  its  peculiar  advantages. 
The  linseed  and  oatmeal  poultices  possess  very  similar 
properties.  They  are  very  compact,  slightly  porous,  and 
retain  their  heat  and  moisture  well.  Linseed  is  somewhat 
irritating  to  certain  skins.  Bread  poultices  are  more  porous, 
cool  more  quickly,  and  dry  more  easily.  Starch  poultices 
are  very  soothing,  and  retain  heat  for  a  considerable  time. 

For  making  poultices  the  water  should  be  boiling,  and  all 
the  materials  ready  to  hand.  A  sufficient  amount  of 
boiling  water  should  be  poured  into  a  heated  bowl,  and 
the  linseed  meal,  etc.,  sprinkled  in,  the  mixture  being 
quickly  stirred  until  the  mass  is  of  a  doughy  consistence. 
This  is  then  rapidly  spread  on  warm  linen,  the  edges  of 
which  are  so  turned  in  as  to  prevent  any  of  the  poultice 
escaping.  Quickness  is  essential  if  the  poultice  is  to  be  hot. 
If  the  water  be  added  to  the  meal,  a  lumpy,  uncomfortable 
mass  will  result,  not  an  evenly  consistent,  soothing  poultice. 

Bread  Poultices  may  be  made  by  cutting  up  stale  bread 


THE  TECHNIQUE  OF  COMPRESSES  129 

into  thick  slices,  pouring  boiling  water  over  them,  and 
soaking  for  a  few  minutes;  or  the  mixture  may  be  simmered 
in  a  saucepan  for  a  short  time.  The  bread  is  then  strained 
and  beaten  up  into  a  paste,  and  spread.  The  poultice  is 
more  porous  if  the  first  method  is  adopted. 

Starch  Poultices. — A  little  cold  water  is  added  to  any 
form  of  starch,  and  a  pulp  made;  sufficient  boiling  water 
is  then  added  and  the  poultice  spread. 

Bran  Poultices  are  often  convenient  on  account  of  their 
lightness.  The  bran  is  placed  in  a  flannel  bag,  and  boiling 
water  poured  on  it. 

Mustard  Applications. — In  making  up  the  mustard  pads, 
a  large  tablespoonful  of  mustard  is  allowed  for  each  pint 
of  boiling  water,  or  a  breakfast-cupful  of  mustard  bran  to 
the  same  amount.  The  cloth  is  wrung  out  of  this  after 
a  minute  has  been  occupied  in  stirring  up  the  mixture  and 
another  minute  for  settling.  For  less  sensitive  skins,  a 
paste  is  made  of  mustard  (and  for  this  the  mustard  bran 
is  quite  strong  enough)  and  spread  on  the  face  of  a  hot 
cloth  with  a  thin  fold  of  muslin  laid  over  it,  and  this  is 
so  expeditiously  applied  as  to  insure  a  hot  application. 
Table  mustard  and  linseed  or  oatmeal  in  equal  proportions 
are  equivalent  in  strength  to  a  like  bulk  of  mustard  bran. 

Mustard  Cloth. — A  piece  of  calico  or  towelling,  fourfold, 
wrung  lightly  out  of  hot  mustard  and  water,  is  applied  as 
hot  as  it  can  be  borne  to  the  part  indicated,  and  kept  in 
close  contact  for  twenty  minutes  at  the  most.  If  felt  too 
acutely,  it  may  be  removed  earlier.  The  effect  of  the  above 
may  be  accentuated  if  it  is  preceded  by  a  hot  fomentation 
for  five  minutes.  This  is  what  is  commonly  done  for — 

The  Liver  Pack. — A  small  blanket  is  laid  across  the  couch 
or  bed,  with  waterproof  material  beneath.  The  patient  lies 
down  on  this,  and  a  hot  fomentation,  large  enough  to 
cover  the  whole  hypochondrium,  is  applied  for  five  minutes, 
and  then  replaced  by  a  mustard  cloth.  The  mustard  cloth 
is  usually  retained  for  fifteen  minutes.  When  patients  are 
intolerant  of  mustard,  the  hot  pad  alone  is  used. 

Mustard  Plaster. — The  following  is  recommended  by 
Whitla  as  a  rapid  and  convenient  method  of  preparing  an 
ordinary  mustard  plaster : 

9 


130        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  required  quantity  of  mustard  is  put  into  a  large  cup 
(about  a  tablespoonful  of  mustard  makes  a  large  sinapism), 
and  as  much  cold  water  is  poured  on  as  will  produce  a  soft 
uniform  cream,  not  quite  so  fluid  as  to  pour  out  readily. 
A  sheet  of  paper  is  procured  of  such  thickness  as  will  readily 
permit  the  fluid  part  of  the  cream  to  soak  through  without 
becoming  too  easily  torn.  Old  newspaper  is  the  best  for 
this  purpose,  and  it  should  be  laid  upon  a  table  or  smooth 
surface,  the  mustard  cream  turned  out  of  the  cup,  and 
roughly  smeared  or  spread  over  its  centre.  The  circum- 
ferential or  clean  parts  of  the  paper  are  folded  over  this, 
making  the  required  shape  and  size  of  the  sinapism,  which 
is  lifted  off  the  table  and  the  surface  which  was  undermost 
applied  to  the  patient's  skin. 

When  the  materials  are  at  hand3  less  than  a  minute  is 
enough  to  perform  this  little  operation.  The  plaster  can 
be  best  carried  to  the  bedside  on  a  plate.  The  mustard 
itself  does  not  actually  come  into  contact  with  the  patient's 
skin,  but  only  the  fluid  which  soaks  through  the  paper 
between  the  skin  and  the  cream. 

The  sinapism  should  be  kept  in  contact  with  the  skin 
by  means  of  a  bandage  or  pad  of  flannel.  It  is  difficult  to 
lay  down  any  absolute  time  during  which  the  plaster  should 
remain  on,  for  it  will  vary  very  much  in  individual  cases. 
After  being  applied  for  a  few  minutes,  however,  the  edge  of 
the  plaster  should  be  raised  and  the  skin  inspected.  If  it 
remains  scarlet  for  a  few  minutes,  the  application  should  be 
removed,  but  if  the  redness  disappears,  the  application 
should  be  continued.  The  twenty  minutes  above  specified 
in  regard  to  mustard  cloth  are  only  approximate,  and 
represent  the  maximum.  To  push  endurance  to  the  point 
of  distress  is  a  mistake,  converting  what  should  be  a  benefit 
into  an  injury.  The  patient  must  be  told  that  when  the 
limit  of  reasonable  endurance  has  been  reached,  he  must 
do  like  Tom  Sawyer,  and  "holler  '  Nuff  !' "  It  must  be 
further  borne  in  mind  that  mustard  applications  are  hurtful 
in  the  extreme  when  the  skin  over  the  part  concerned  is 
inflamed,  or,  indeed,  shows  any  form  of  irritation.  In  such 
circumstances  a  plain  hot  pad  without  mustard  must 
suffice. 


THE  TECHNIQUE  OF  COMPRESSES 


131 


The  lee-Bag. — Of  this  there  are  various  forms.  That 
we  are  most  familiar  with  is  the  small  ice-bag  which  we  see 
in  the  wards  of  any  hospital  (Fig.  70).  It  is  a  small  bag  of 
rubber  provided  with  a  metal  cap  and  filled  with  broken  ice. 
The  ice-helmet  is  a  modification  of  this;  and  there  is  also 
the  well-known  Chapman's  spinal  ice-bag  (Fig.  71).  Various 


FIG.  70. — ICE-BAG. 

appliances  are  now  made  of  Leiter's  tubing,  whereby  ice- 
cold  water  may  be  allowed  to  flow  in  immediate  proximity 
to  any  inflamed  region,  and  the  cooling  effect  of  such  an 
appliance  is  considerably  greater  than  an  ice-bag. 

Such  appliances  are  of  great  use  in  spinal  injuries,  and 
congestions,  acute  myelitis,  and  spinal  or  cerebral  menin- 
gitis. Opinions  differ  somewhat  as  to  the  value  of  an  ice 
bag  in  pleurisy.  Affleck  considers  it  a  most  valuable  method 


FIG.  71. — CHAPMAN'S  SPINAL  ICE-BAG. 


of  treatment  and  very  soothing  to  the  patient,  while  Kellogg 
considers  it  is  contra-indicated.  The  latter,  however, 
speaks  highly  of  the  ice-collar  in  diphtheria,  when  applied 
for  fifteen  or  twenty  minutes  in  place  of  a  fomentation. 
The  effect  is  to  decrease  the  hypersemia  of  the  affected  area 
reflexly,  and  also  by  contraction  of  the  carotids. 


132        MANUAL  OF  PHYSIO-THERAPEUTICS 

Chapman  made  a  variety  of  claims  for  his  spinal  ice-bag 
which  have  been  more  or  less  substantiated.  He  found 
it  had  a  sedative  influence  on  the  spinal  cord,  but  also 
that  he  could  to  some  extent  increase  or  diminish  the  cir- 
culation in  any  part  of  the  trunk  by  varying  the  part  of  the 
spine  to  which  he  applied  the  bag.  If  he  wished  to  influence 
the  head,  he  applied  the  bag  to  the  neck  and  shoulders; 
if  the  chest  and  arms,  he  applied  it  to  the  upper  part  of  the 
back;  and  to  the  lumbar  region  for  the  pelvis  and  legs. 
In  this  way  he  could  influence  the  occurrence  of  menstrua- 
tion, and  he  states  that  after  a  brief  application  to  the  lower 
dorsal  region  he  has  seen  the  feet  become  very  rapidly 
warm.  He  also  found  it  useful  in  sea-sickness  and  the 
vomiting  of  pregnancy.  By  filling  the  bag  with  hot  water, 
on  the  other  hand,  he  could  induce  contraction  in  the 
vessels  which  were  dilated  by  the  application  of  cold,  and 
was  in  this  manner  able  to  arrest  menorrhagia,  epistaxis, 
and  other  haemorrhages. 


CHAPTER  V 
NAUHEIM  BATHS 

THESE  baths  have  been  known  for  about  half  a  century, 
and  many  physicians  of  repute  have  advised  their  employ- 
ment in  the  treatment  of  various  forms  of  cardiac  disability. 
The  water  used  in  the  baths  is  charged  in  varying  degree  with 
carbonic  acid  gas,  and  containing  small  quantities  of  saline 
matter,  such  as  chloride  and  sulphate  of  soda. 

The  specific  gravity  varies,  but  averages  about  1005. 
At  Nauheim  the  springs  used  for  this  purpose  contain 
chloride  of  sodium,  chloride  of  calcium,  and  a  varying  amount 
of  C02.  The  "  Neuer  Sprudel  "  contains  only  approximately 
1  litre  of  gas,  while  the  "Grosser  Sprudel  "  contains  over 
3  c.c.  per  litre.  The  course  of  baths  is  always  commenced 
with  the  springs  weak  in  carbonic  acid  gas;  indeed,  at  the 
start  the  waters  are  allowed  to  give  off  the  whole  of  their  gas 
before  the  bath  is  taken,  while  some  "mutterlauge  "  rich 
in  calcium  chloride  and  bromine  is  added  to  them.  Later 
a  spring  the  water  of  which  is  richer  in  CO2  is  used,  and  this 
is  gradually  increased  until  strong  carbonaceous  waters 
flowing  continuously  in  and  out  of  the  bath  are  employed 
("  Sprudel  strombad  "). 

The  action  varies  with  the  temperature  and  degree  of 
carbonization  of  the  water  employed.  Small  bubbles  of  gas 
adhere  to  the  skin  of  the  patient,  which  is  powerfully  stimu- 
lated thereby  and  becomes  reddened.  There  is  a  sensation 
of  heat  and  prickling  and  some  degree  of  hyperasthesia. 
The  cutaneous  vessels  ("peripheral  heart")  become  sur- 
charged with  blood,  to  the  relief  of  the  chronically  over- 
loaded and  halting  ventricles. 

One  of  the  advantages  of  this  bath  is  that  it  can  be  given 
practically  anywhere  by  means  of  the  artificially  prepared 

133 


134        MANUAL  OF  PHYSIO-THERAPEUTICS 

water.  There  are  several  good  preparations  on  the  market 
for  this  purpose,  among  the  best  known  being  the 
"Croyden,"  recommended  by  Bezly  Thome,  consisting 
of  bicarbonate  of  soda  and  acid  sulphate  of  soda 
tablets. 

These  preparations  are  put  up  in  boxes  containing  four 
packets  of  bicarbonate  of  soda  and  eight  tablets  of  acid 
sulphate  of  soda.  Eight  parts  of  the  former  exactly  neu- 
tralize twelve  parts  of  the  latter,  but  the  alkali  should  always 
be  in  excess.  Thirty-two  ounces  bicarbonate  of  soda, 
with  22  ounces  of  acid  sulphate,  will  make  a  good  bath  of 
40  gallons,  and  will  generate  about  250  c.c.  of  gas  per  litre 
of  water.  A  whole  packet  of  Sandow  should  be  added  to 
40  gallons  of  water  containing  about  10  pounds  of  chloride 
of  sodium  and  10  ounces  of  chloride  of  calcium  to  make  a 
strong  bath. 

At  the  commencement  of  treatment,  however,  where  no 
effervescence  is  desired,  the  bath  can  be  made  up  with 
4  pounds  of  chloride  of  sodium  and  6  ounces  of  chloride  of 
calcium.  Later,  half  a  box  may  be  added  to  this,  and  later 
again  a  whole  box  used  with  the  stronger  brine.  The 
material  for  the  brine  can  be  easily  obtained  from  the  Salt 
Union  at  Nantwich. 

The  temperature  of  the  water  varies  from  36°  C.  to  30°  C., 
beginning  at  the  higher  temperature  and  being  gradually 
lowered. 

Carbonic  acid  gas  is  best  obtained  in  large  institutions 
and  hospitals  by  means  of  the  special  apparatus  of  the 
Fischer  Kiefer  Co.  of  Zurich  (Fig.  74).  This  produces  a 
more  even  carbonization  of  the  water  than  is  possible 
with  powders,  but  is,  of  course,  too  elaborate  and  expensive 
a  method  for  private  houses.  An  enterprising  medical 
man  we  know  obtained  his  CO.,  by  means  of  the  plant  of 
an  aerated  water  manufacturer  whose  premises  adjoined 
his  own  ! 

Technique  of  the  Bath. 

The  patient  should  recline  at  an  angle  of  about  45  degrees, 
with  his  entire  body  up  to  the  head  and  neck  immersed  in 
water  (Fig.  74).  The  bathroom  should  be  well  ventilated, 


NAUHEIM  BATHS  135 

and  the  patient  should  breathe  regularly,  abstaining  from 
conversation. 

Some  sense  of  oppression  is  commonly  felt  at  first,  but 
will  soon  pass  off  if  the  patient  takes  two  or  three  deep 
inspirations,  "  which  facilitate  the  passage  through  the 
pulmonary  circuit  of  the  blood  which  is  being  driven  through 
the  right  heart  from  the  splanchnic  and  other  venous 
reservoirs."  The  patient  must  leave  the  bath  at  the  exact 
time  prescribed,  and  be  at  once  enveloped  in  a  warm  bath 
towel,  and  carefully  rubbed  dry  by  the  bath  attendant. 
He  should  then  lie  down  on  a  couch  in  an  adjoining  apart- 
ment, and  rest  for  at  least  an  hour  before  dressing. 

The  duration  of  the  bath  and  the  strength  of  the  con- 
stituents must  vary  with  each  individual  and  the  stage 
of  treatment.  In  many  cases  careful  observation  on  the 
part  of  the  physician  himself  is  desirable. 

The  baths  are  usually  taken  in  a  course  of  twelve,  and 
rarely  should  more  than  three  be  taken  in  each  week. 
On  the  days  on  which  there  is  no  bath  the  patient  is  put 
through  the  Schott-Nauheim  exercises. 

The  Effect  of  the  Baths  and  Exercises  on  the 
Circulatory  Organs. 

In  all  conditions  dependent  on  arterio-sclerotic  changes 
and  atheroma,  such  as  commencing  aneurism,  congestion  of 
the  abdominal  viscera,  and  imperfect  emptying  of  the 
heart,  if  the  tissue  changes  have  not  passed  beyond  the 
reach  of  repair,  frequently  relief  and  sometimes  cure  may  be 
afforded  by  the  suitable  use  of  the  Schott-Nauheim  system. 
It  has,  indeed,  been  proved  beyond  reasonable  doubt  that 
early  conditions  of  arterial  degeneration  can  be  greatly 
ameliorated  by  this  method  of  treatment,  and  to  a  much 
greater  degree  than  can  be  effected  by  any  known  drug 
or  combination  of  drugs.  By  this  treatment  the  heart  is 
stimulated  to  more  complete  systole,  and  residual  blood  is 
expelled,  while  the  peripheral  resistance  in  the  circulation 
is  diminished.  Benefit  is  always  derived  where  it  is  to 
the  advantage  of  the  patient  to  restore  healthy  substance 
and  proportionate  working  capacity  to  the  myocardium. 


136        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  beneficial  action  is  only  limited  by  the  degree  of  ob- 
struction in  the  nutrient  arteries  and  the  degeneration  of 
their  coats.  If  these  changes  are  far  advanced,  then  in- 
creased force  in  the  cardiac  systole  will  only  accelerate  the 
degeneration  and  hasten  the  end.  While  reparative  pro- 
cesses take  place  with  readiness  in  the  coronaries  and  the 
myocardhim,  organic  changes  in  the  valves  from  chronic 
endocarditis  are  beyond  the  range  of  any  line  of  treatment. 

It  may  be  said  that  in  valvular  lesions  the  well-being  and 
duration  of  life  of  the  patient  depend  on  the  measure  of 
compensatory  hypertrophy  and  the  absence  of  myocardial 
degeneration.  This  is  probably  more  true  of  aortic  re- 
gurgitation  than  of  any  other  lesion. 


FIG.  72. — DIAGRAM  OF  CARDIAC  DULNESS  AS  AFFECTED  BY 
NAUHEIM  BATHS. 

In  short,  the  Nauheim  treatment  is  of  the  highest  efficacy 
in  establishing  compensation  in  valvular  disease  of  what- 
ever nature,  and  restoring  the  myocardium  to  a  healthy 
condition. 

In  cases  of  cardiac  dilatation  the  diminution  of  the 
area  of  cardiac  dulness  is  very  striking.  Indeed,  Kellogg 
states  that  after  one  bath  he  has  found  the  superficial 
dulness  1  inch  less  in  its  transverse  diameter  in  cases 
of  marked  dilatation  and  loss  of  compensation. 

It  is  well  to  keep  a  record  of  such  cases  by  a  simple  dia- 
gram such  as  Fig.  72. 


NAUHEIM  BATHS 


137 


The  Schott  Brothers  have  also  emphasized  the  value  of 
the  baths  in  this  respect,  having  found  a  progressive  and 
appreciable  reduction  in  the  area  of  cardiac  dulness  after 
a  short  course  of  these  baths  (Fig.[73). 


FIG.  73. — PULSE-TRACING:  (a)  BEFORE,  (b)  AFTER  A 
FOUR-WEEK  COURSE  OF  NAUHEIM  BATHS. 


The  Schott-Nauheim  Exercises. 

Technique. — The  body  should  be  held  upright  and  joints 
kept  straight.  The  resistance  applied  should  not  be  suffi- 
cient to  cause  any  shortness  of  breath  or  tremor  in  the 
patient's  limbs. 

The  resistance  may  be  applied  by  the  patient  himself 
putting  into  action  the  opposing  muscles  to  those  which 
effect  the  movement,  or  by  an  attendant,  commonly  called 
"the  operator."  Each  movement  should  be  performed 
slowly  and  evenly,  at  a  uniform  rate,  and  not  repeated 
twice  in  the  same  limb  or  group  of  muscles.  The  patient's 
breathing  should  riot  be  accelerated,  and  any  duskiness 
or  pallor  of  the  cheeks,  yawning,  dilatation  of  the  alae 
nasi,  or  drawing  in  of  the  corners  of  the  mouth,  must  be 
taken  as  a  signal  for  the  immediate  suspension  of  the 
movements.  In  order  to  prevent  the  patient  closing  the 
glottis  and  holding  his  breath,  he  should  be  told  to  keep 
counting  in  a  whisper. 


138         MANUAL  OF  PHYSIO-THERAPEUTICS 


THE  EXERCISES. 

1.  The  arms  are  to  be  raised  slowly  outwards  from  the 
side  until  they  are  on  a  level  with  the  shoulder.     After  a 
pause  they  should  be  slowly  lowered. 

2.  The  body  should  be  inclined  sideways  as  much  as  pos- 
sible towards  the  right,  and  then  to  the  left. 

3.  One  leg  should  be  extended  as  far  as  possible  sideways 
from  the  body,  the  patient  steadying  himself  by  holding  on 
to  a  chair.     The  leg  is  then  dropped  back.     The  same  move- 
ments are  repeated  by  the  other  leg. 

4.  The  arms  are  raised  in  front  of  the  body  to  a  level  with 
the  shoulder,  and  then  put  down. 

5.  The  hands  are  rested  on  the  hips,  and  the  body  is  bent 
forwards  as  far  as  possible,  and  then  raised  to  the  upright 
position. 

6.  One  leg  is  raised  with  the  knee  straight  forwards  as  far 
as  possible,  then  brought  back.     This  movement  is  repeated 
with  the  other  leg. 

7.  With  the  hands  on  the  hips,  the  body  is  twisted  round 
as  far  as  possible  to  the  right,  and  then  again  to  the  left. 

8.  With  the  hands  resting  on  a  chair  and  the  back  stiff 
and  straight,  each  leg  is  raised  as  far  as  possible  backwards, 
first  one  and  then  the  other. 

9.  The  arms  are  extended  and  the  fists  supinated.     The 
arms  are  then  extended  outwards,  next  inwards,  at  the  height 
of  the  body. 

10.  Each  knee  is  first  raised  as  far  as  possible  to  the  body, 
and  then  the  leg  extended. 

11.  This  movement  is  the  same  as  No.  9,  but  with  the 
fists  pronated. 

12.  Each  leg  is  bent  backwards  from  the  knee,  and  then 
straightened. 

13.  Each  arm  is  bent  and  straightened  from  the  elbow. 

14.  The  arms  are  brought  from  the  sides  forwards  and 
upwards,  then  downwards  and  back  as  far  as  they  will  go, 
the  elbows  and  the  hands  being  straight. 

15.  The  arms  are  put  at  a  level  with  the  shoulder,  and 
then  bent  from  the  elbows  inwards  and  again  extended. 


NAUHEIM  BATHS  139 

16.  With  the  arms  in  front  at  the  level  of  the  shoulder, 
and  the  hands  stretched,  the  arms  are  opened  out  sideways 
and  then  brought  together. 

17.  The  arms  are  bent  from  the  elbow  outwards  and  ex- 
tended. 

Bezly  Thome  enumerates  the  following  conditions  as 
suitable  for  Nauheim  treatment : 

Palpitation,  with  and  without  hyperpyesis. 

The  strained  heart  of  athletes. 

Cardiac  dilatation,  with  "air-hunger  "  symptoms. 

Petit  mal  (of  the  cardiac  type). 

Cerebral  neurasthenia. 

Tachycardia  and  bradycardia,  exophthalmic  goitre. 

Cheyne-Stokes  breathing  dependent  on  arterio-sclerosis. 

Summary  of  Action.— The  primary  effect  in  most  cases 
is  to  reduce  the  pulse-rate  by  4  to  6  beats  per  minute, 
while  the  pulsations  are  rendered  more  vigorous  owing  to 
the  improved  coronary  flow.  The  cutaneous  vessels  become 
dilated  and  hypersemic,  while  the  internal  vessels  are  con- 
tracted. The  output  of  urine  and  CO.,  are  both  increased. 
There  is  a  more  complete  contraction  of  the  right  ventricle, 
and  increased  vascular  tonus  throughout  the  whole  circula- 
tory system.  There  is  a  marked  improvement  in  the  general 
health  and  nutrition  of  the  patient. 

The  opinions  of  some  of  the  leaders  in  medicine  on  the 
subject  of  these  baths  are  of  interest.  Douglas  Powell 
says:  "The  employment  of  carefully  graduated  and  ob- 
served exercises  of  Schott  may  be  regarded  as  especially 
adapted  for  the  treatment  of  the  flabby,  irritable,  '  stuffy  ' 
hearts- — cases  of  fatt}"  infiltration  and  impaired  metabolism 
—which  are  met  with  in  people  of  venous  plethora. 

"In  cases  of  chlorosis  with  dilated  heart,  after  a  pre- 
liminary week  or  two  of  complete  rest,  the  Schott  treatment 
is  of  value  when  combined  with  a  chalybeate  and  a  dry 
bracing  climate. 

"In  the  first  commencing  failure  of  heart  in  chronic 
valve  disease,  the  treatment  may  be  employed  combined 
with  a  more  or  less  complete  cessation  from  other  forms 


140         MANUAL  OF  PHYSIO-THERAPEUTICS 

of    exercises,   and    similarly  after   such    cases    have  been 
restored  up  to  a  certain  point  by  digitalis  treatment. 

"Further,  certain  cases  from  the  symptoms  of  which  we 
recognize  the  presence  of  atheromatous  changes  in  the 
coronary  vessels,  the  treatment  may  be  cautiously  tried 
in  combination  with  much  rest.  The  treatment  is  un- 
doubtedly an  aid  to  our  therapeutics." 

Broadbent's  opinion  was  as  follows:  "In  cases  of  cardiac 
dilatation  from  loss  of  tone  of  the  heart  after  influenza  or 
some  depressing  disease,  it  may  be  of  great  service,  and  effect 
a  cure  where  drugs  and  other  treatment  have  failed. 

"In. many  cases  of  functional  and  neurotic  heart  disease, 
which  are  commonly  difficult  to  deal  with,  it  may  also  give 
satisfactory  results. 

"In  valvular  disease,  it  is  of  course  unnecessary  when 
compensation  has  been  established  and  no  symptoms  are 
present;  when  compensation  has  completely  broken  down 
it  is  not  advisable  to  rest  in  bed,  and  suitable  treatment 
by  other  means  may  be  more  efficacious. 

"Incases  of  mitral  disease,  more  especially  mitral  steno- 
sis, when  compensation  is  just  maintained  with  difficulty, 
when  the  degree  of  stenosis  is  such  that  increased  contractile 
power  of  the  right  ventricle  induced  by  digitalis  would  be 
useless  or  harmful,  it  may  be  of  great  service.  In  aortic 
disease  it  is  not  advisable,  owing  to  the  risks  of  syncopal 
attacks,  though  when  compensation  is  breaking  down  it  may 
sometimes  yield  good  results.  In  adherent  pericardium, 
with  threatened  compensatory  failure,  it  may  be  of 
service." 

Professor  Lindsay  says:  "I  must  confess  I  read  with 
some  incredulity  the  reports  of  rapid  diminution  of  cardiac 
dilatation  under  this  treatment,  and  I  entertain  no  doubt 
that  increased  expansion  of  the  lungs  is  the  main  factor  in  the 
alteration  of  the  percussion  area  of  the  heart  which  has  been 
described."  While  admitting  slight  experience  of  the 
method,  Lindsay  considers  "the  advantages  consist  in 
the  methods  employed  being  thoroughly  systematized, 
controlled,  and  regulated." 

Strumpell  writes:  "The  employment  of  baths  in  heart 
disease  deserves  special  consideration.  Numerous  ex- 


NAUHEIM  BATHS 


141 


periences  go  to  prove  that  they  are  well  borne,  not  only  by 
patients  with  heart  disease,  but  that  they  exercise  peculiar 
and  beneficial  and  invigorating  influence  on  the  action  of 
the  heart." 


FIG.  74. — THE  FISCHER  KIEFEK  C02  GENERATOR  FOR 
XAUHEIM  BATH. 


In  view  of  the  above  there  seems  to  be  no  room  for 
scepticism  or  reasonable  doubt  that  the  use  of  Nauheim 
baths  and  exercises  in  many  cardiac  and  associated  con- 
ditions is  in  the  clearest  manner  indicated. 


142        MANUAL  OF  PHYSIO-THERAPEUTICS 

Centra-Indications. — In  cases  with  albuminuria  due  to 
chronic  Bright 's  disease  (large  white  kidney),  it  is  better  not 
to  prescribe  these  baths. 

They  are  also  unsuitable  when  the  patient  is  suffering 
from  eczema,  from  angina  pectoris  associated  with  cardiac 
asthma,  or  from  marked  oedema  or  peripheral  neuritis. 


Peat,  Fango,  and  Other  Medicated  Baths. 

These  are  semi-solid  baths  of  varying  density  and  tem- 
perature; with  them  may  be  included  the  "hot  sand" 
bath  and  the  hot  seaweed  bath.  They  are  used  chiefly 
for  their  thermic  and  mechanical  effects,  but  also  to  some 
extent  for  their  chemical  action. 

Peat  is  a  form  of  turf  soil  consisting  of  dried  and  de- 
composed vegetable  matter  which  has  undergone  certain 
chemical  changes  induced  by  constant  intimate  contact  with 
mineral  matter  percolating  through  it  for  thousands  of  years. 
Apart  from  dried  grass  fibre,  root  and  bituminous  substances, 
it  contains  silica,  phosphate  and  sulphate  of  iron,  sodium 
chloride,  and  sulphuretted  hydrogen,  as  well  as  sulphuric  and 
carbonic  acid.  After  undergoing  complete  disintegration 
by  exposure  to  the  weather,  the  peat— by  admixture  with 
hot  water — is  made  into  a  soft  mush  or  mud,  of  the  con- 
sistence of  fine  porridge,  practically  free  from  grit.  The 
amount  and  nature  of  the  chemical  salts  present  in  the 
peat  from  any  district  will,  of  course,  depend  on  the  nature 
of  the  springs  in  the  district  and  the  amount  and  quality 
of  saline  matter  they  contain.  Sulphates,  carbonates,  and 
chlorides  can  be  added  to  the  hot  water  prior  to  mixing  it 
with  the  peat. 

The  peat  baths  at  Marienbad  are  ferruginous  in  character, 
and  those  at  Driburg  sulphurous. 

Action. — A  peat  bath  exerts  a  considerable  mechanical 
effect,  resembling  that  of  massage,  through  compression  and 
friction.  The  capacity  of  peat  for  retaining  heat  is  much 
greater  than  water,  and  these  baths  can  be  employed  at 
much  higher  temperatures  than  water  baths.  The  motor 
and  sensory  cutaneous  nerves  are  markedly  stimulated. 


NAUHEIM  BATHS  143 

Fango  Di  Battaglia. — Fango  is  the  volcanic  mineral  de- 
posit from  the  hot  springs  of  Battaglia,  near  Padua.     It 
has  been  used  for  centuries  by  the  Italians  for  the  relief  and 
cure  of  painful  affections,  such  as  sciatica,  lumbago,  gout, 
rheumatism,  etc. 

Its  value  being  recognized  by  visitors  to  Battaglia,  it  was 
imported  to  some  of  the  Continental  bathing-places,  and  its 
properties  were  tested  under  skilled  and  scientific  observa- 
tion.    The  results  were  so  satisfactory  that  it  has  been 
gradually  adopted  at  the  principal  health  resorts,  which  now 
owe  a  great  part  of  their  success  to  the  results  of  fango 
treatment.     At  Baden-Baden,  Kissingen,  etc.,  its  use  has 
greatly    increased.     The    use    of    fango    dates   from    very 
early  times.     Under  the  Roman  Empire  the  applications 
of  this  material  at  the  Eugean  Thermae  were  noted  for 
their  excellent  effects.* 

In  appearance  fango  is  a  soft,  greyish-brown,  plastic  sub- 
stance of  the  consistence  of  butter,  and  equally  soft  to  the 
touch.     It  is  odourless,  and  after  the  application  is  finished 
can  be  quickly  and  completely  removed  from  the  skin  by 
means  of  a  douche  of  warm  water,  leaving  the  skin  surface 
absolutely  clean. 

Chemical  Analysis. — Fango  is  rich  in  iron,  argillaceous 
earth,  magnesia,  lime,  and  alkalies,  united  with  phosphoric 
and  sulphuric  acids. 

In  100  Parts. 
Combustible  and  volatile  matter  . .          . .          . .        10-98 

Soluble  in  acids        . .          . .          . .          . .          . .        41-36 

Insoluble 58-64 

The  portion  soluble  in  acids  is  composed  of— 

Carbonic  acid            .  .  . .          . .          .  .  . .  9-34 

Sulphuric  acid          .  .  .  .          . .          .  .  .  .  6-65 

Silica .  .  7-86 

Oxide  of  iron             .  .  .  .          .  .          . .  . .  9-81 

Phosphates 1-83 

Carbonate  of  lime     . .  .  .          .  .          .  .  .  .  6-05 

Magnesia       . .          . .  .  .          .  .          . .  . .  1-40 

Potassium  j  ag  gulhates  0.94 
Sodium      .1 


*  Fango  baths  were  first  introduced  into  this  country  at  the  bath- 
ing establishment  connected  with  the  Royal  Hotel,  Matlock  Bath. 


1  U        MANUAL  OF  PHYSIO-THERAPEUTICS 

In  addition,  there  are  traces  of  the  rarer  minerals,  such  as 
thorium,  helium,  and  radium. 

In  order  to  bring  the  fango  to  a  proper  temperature  for 
application  to  the  body,  it  is  heated  in  a  large  water- jacketed 
or  steam-jacketed  pan.  The  temperature  at  which  it  is 
applied  is  a  most  important  point,  and  it  is  essential  that 
the  heat  should  be  easily  controlled.  The  apparatus  in 
general  use  is  a  large  tinned  copper  pan  with  a  lid.  The  pan 
is  surrounded  by  a  water  chamber,  and  the  latter  is  heated 
by  a  number  of  large  gas  Bunsen  burners.  The  heating 
takes  place  but  slowly,  but  the  cooling  is  equally  slow,  and 
when  once  a  large  mass  of  fango  is  raised  to  proper  tem- 
perature, it  takes  some  hours  to  cool.  The  application 
is,  indeed,  a  large  sterilized  mineral  poultice  enveloping 
the  affected  part  (Figs.  75  and  76). 

Temperature  and  Duration  of  Application. — It  was  at 
first  thought  important  to  obtain  as  high  a  temperature 
as  possible  in  the  fango  treatment,  but  this  was  an  erro- 
neous idea.  The  following  rules  should  be  observed  in  a 
general  way : 

To  begin  with,  a  low  temperature  should  be  used,  and 
gradually  raised  by  a  degree  or  so  at  a  time.  A  low  tem- 
perature for  fango  is  45°  C. ;  the  highest  temperature  en- 
durable is  56°  to  58°  C.,  at  which  signs  of  burning  show 
themselves.  Generally  speaking,  a  temperature  of  54°  to 
55°  C.  is  sufficient. 

The  higher  temperatures  are  only  useful  in  the  treatment 
of  deep-lying  abdominal  or  thoracic  viscera.  For  all  kinds 
of  neuralgias  low  temperatures  (45°  C.)  are  advisable. 
With  old  or  weak  patients  the  temperature  should  never 
exceed  49°  C.,  and  the  packs  be  given  only  on  alternate 
days.  Packing  should  not  take  longer  than  thirty-five  to 
forty-five  minutes. 

For  washing  off  the  fango,  a  warm  douche  or  spray  is 
recommended.  General  baths  are  not  desirable.  Neuras- 
thenics, and  those  suffering  from  some  other  nervous  com- 
plaints, usually  require  a  cold  douche  after  the  warm  one, 
followed  by  a  rubbing  down. 

Reaction. — The  patient  should  be  warned  at  the  com- 
mencement that  a  reaction  takes  place  (and  sometimes  even 


NAUHEIM  BATHS  145 

repeats  itself).  During  the  time  of  this  reaction,  which 
usually  appears  after  a  few  applications,  the  affected  part  is 
frequently  much  more  painful  and  sensitive.  After  a  few 
more  applications  the  pain  subsides  again,  and  usually  a 
steady  improvement  sets  in. 

Fango  treatment  can  be  employed  from  infancy  to  old 
age,  and  with  every  constitution,  even  with  such  as  suffer 
from  severe  heart  complaints.  Cases  with  high  fever, 
advanced  phthisis,  or  women  who  are  enceinte,  should  not 
be  treated  with  fango. 

A  very  important  point  in  fango,  as  well  as  in  every 
other  thermal  treatment,  is  that  the  physician  should 
keep  a  sharp  eye  on  the  patient,  especially  at  the  beginning, 
and  see  him  after  every  third  and  fifth  packing ;  and  also 
that  he  adapts  his  prescriptions  to  the  individual  case. 

The  Action  of  Fango. — The  action  of  fango  must  be 
considered  in  a  threefold  aspect :  the  chemical,  the  me- 
chanical, and  the  thermal.  The  chemical  effect  has  not 
yet  been  made  sufficiently  clear,  and  there  are  great  differ- 
ences of  opinion  concerning  it.  The  mechanical  effect 
consists  in  the  pressure  exercised  by  the  layers  of  fango, 
which  act  like  a  gentle  massage.  The  cause  of  the  thermal 
action  is,  of  course,  to  be  found  in  the  high  temperature  to 
which  fango  has  to  be  brought ;  a  balancing  of  the  heat  of 
the  body  and  the  heat  of  the  fango  takes  place,  and  the  body 
remains  always  under  the  same  warming  layer. 

The  physiological  effect  of  fango  applications  on  the  blood- 
pressure,  the  distribution  of  the  blood,  and  on  the  heart, 
may  be  shortly  expressed  as  follows:  According  to  many 
observations  the  frequency  of  the  pulse  is  diminished  at  the 
beginning  of  the  application,  becomes  greater  after  about  ten 
minutes  (an  increase  of  6  to  8  per  minute),  then  diminishes 
again  by  2  to  3  per  minute,  and  after  this  remains  stationary 
until  the  end  of  the  application.  The  application  is  im- 
mediately followed  by  an  increased  tonus  of  the  blood- 
vessels, this  being  the  consequence  of  the  irritation  of  the 
vaso-constrictors ;  the  skin  becomes  pale ;  the  blood-pressure 
is  heightened  for  a  short  time;  then  a  hypera3mia  of  the 
cuticle  takes  place  through  paralysis  of  the  constrictors, 
and  with  it  a  reduction  of  the  heart  action  in  consequence 

10 


146        MANUAL  OF  PHYSIO-THERAPEUTICS 

of  diminished  resistance.  According  to  Baelz,  this  paralysis 
is  not  annulled  by  cold,  and  patients  could  leave  the  bath- 
ing-house undressed,  even  in  winter,  without  catching  cold. 

The  reflex  action  of  the  sensory  and  temperature  nerves 
on  the  heart  is  kept  up;  a  douching  with  cold  water  is  at 
once  followed  by  a  decrease  of  the  number  of  pulse  strokes, 
and  by  a  strengthening  of  the  heart  action,  without  diminu- 
tion of  the  redness  of  the  skin.  Baelz  noticed  also  that 
the  blood  of  ansemic  patients  is  greatly  improved  after 
a  fango  application.  The  temperature  of  the  body  is 
heightened  during  the  application,  particularly  during  the 
first  quarter  of  an  hour  (1°  to  1-5°  C.  or  more).  According 
to  Maggiora  and  Levy,  this  is  not  so  much  the  result  of 
a  lessening  of  the  radiation  of  heat  as  of  a  direct  heating 
of  the  blood  through  the  far  hotter  fango.  In  the  beginning 
of  the  application  a  diminished  frequency  of  respiration  is 
observable,  which  increases  after  about  ten  minutes  by 
four  .or  five  breaths,  without  being  followed  later  on  by 
oppression  or  deeper  breathing. 

A  fango  application  does  not  relax  the  muscles,  and  very 
little  fatigue  is  subsequently  felt.  An  increased  secretion 
of  nitrogen  can  be  proved  either  in  the  perspiration  or  in 
the  urine.  Gout  especially  produces  an  increased  secretion 
of  uric  acid.  The  action  of  fango  on  the  nerves  differs 
according  to  the  temperature  employed;  it  either  promotes, 
hinders,  or  altogether  stops  their  action.  The  physiological 
facts  justify  its  employment  in  the  following  ways:  Fango 
is,  first,  the  best  cataplasm  known.  Its  density,  its  even 
consistency,  its  low  specific  heat,  the  fact  of  its  being  a 
non-conductor  of  heat,  and  the  mild  counter-irritation  it 
produces  on  the  cuticle,  permit  it  to  act  for  a  long  time  on  a 
considerable  area  of  the  body,  even  when  brought  to  a  high 
temperature,  without  substantially  disturbing  either  the 
pulse,  the  blood-pressure,  or  the  heart  action,  without 
producing  congestions  and  oppressions,  or  leaving  behind 
(like  other  kinds  of  baths)  a  great  feeling  of  relaxation  and 
fatigue.  Secondly,  fango  is  an  excellent  diaphoretic. 

Through  its  action  on  the  distribution  of  the  blood  in 
the  organism  fango  has  a  diverting  effect,  while  in  the 
cuticle  it  produces  hypersemia.  In  both  cases  the  effect 


NAUHEIM  BATHS  147 

is  an  intensive,  passive  one,  with  diminished  tonus  of  the 
vascular  system  of  long-continued  duration.  We  are 
therefore  able  not  only  to  effect  a  momentary  lessening  of 
congestion  in  cases  of  hypersemia  of  the  inner  organs  as  well 
as  of  the  mucous  membranes  of  the  respiratory  and  intestinal 
tracts,  and  in  hypersemia  of  the  brain  and  its  membranes, 
but  the  effect  endures,  and  by  a  methodical  continuation 
of  the  treatment  the  vessels  of  the  affected  parts  will  by 
degrees  resume  their  normal  tonicity  and  fulness. 

On  the  other  hand,  fango  applications  produce  an  increased 
supply  of  blood  of  a  higher  temperature,  with  consequent 
perspiration,  in  rheumatic  affections  of  the  joints  and  of  the 
nerves,  and  in  this  manner  they  promote  the  resorption 
of  all  sorts  of  effusion,  and  particularly  of  perimetritic 
exudate,  as  well  as  gouty  deposits,  etc. 

Combined  with  a  suitable  diet,  fango  treatment  is  of 
great  advantage  in  affections  of  the  intestinal  tract,  especi- 
ally in  chronic  catarrh  of  the  bowels. 

Rheumatism,  Subacute  or  Chronic,  will  always  be  one 
of  the  chief  indications  for  fango  treatment.  The  results 
obtained  are  completely  successful.  Cases  usually  come 
under  treatment  after  having  suffered  some  time.  The 
reaction  may  take  two  or  three  days,  and  according  to  its 
intensity  the  doctor  will  continue  or  discontinue  the  pack 
for  two  or  three  days,  or  else  lower  the  temperature.  After 
a  thorough  improvement  has  taken  place  it  is  advisable  to 
give  five  to  ten  more  packs,  so  as  to  prevent  a  relapse. 

Chronic  Articular  Rheumatism  (in  all  its  Stages. — The 
greatest  field  for  fango  treatment  is  offered  by  this  com- 
plaint. The  packs  are  first  applied  at  46°  (.'.,  the  tem- 
perature being  increased  by  about  1°  daily  till  53°  to 
54°  C.  is  reached.  In  this  complaint  the  temperature 
should  be  increased  in  spite  of  the  reaction,  which  takes 
place  usually  after  the  second  until  the  sixth  packing, 
and  lasts  from  two  to  five  days.  Only  with  a  very 
acute  reaction  should  the  temperature  be  lowered.  In 
the  general  course  of  treatment,  reactions  often  take  place 
later  on.  These  are~  usually  rather  intense,  but  do  not 
last  more  than  a  day  or  so,  and  generally  announce  a  new 
amelioration. 


148        MANUAL  OF  PHYSIO-THERAPEUTICS 

If  the  joint  becomes  swollen  by  fluid  effusion,  skilful 
massage  may  be  required.  Often  rather  large  sy  no  vial 
effusions,  occurring  during  the  first  few  packs,  go  down 
after  a  little  time  by  merely  continuing  the  packs.  As  a 
rule,  use  massage  in  cases  where  it  appears  to  be  called 
for  (e.g.,  in  contractions  and  thick  old  effusions)  only  after 
the  reaction,  and  call  the  attention  of  the  patient  to  the 
fact  that  an  increase  of  pain  may  at  first  result  from  the 
massage. 

Rheumatoid  Arthritis. — Massage  is  generally  given  from 
the  beginning,  except  where  the  joints  are  very  painful. 
An  improvement  almost  invariably  takes  place,  the  intense 
pains  are  alleviated,  and  for  a  time  they  may  disappear 
entirely.  The  treatment  should  be  of  longer  duration,  and 
repeated  at  intervals  of  six  months  at  least. 

Muscular  Rheumatism. — The  fango  is  applied  first  at 
47°  C.,  and  gradually  raised  as  high  as  bearable.  Re- 
action is  rapid  and  brief,  and  recovery  usually  quickly 
follows. 

In  old  and  chronic  cases,  such  as  lumbago,  the  reaction 
is  delayed,  occasionally  not  appearing  till  after  fifteen  or 
twenty  packs ,  but  the  case  then  makes  satisfactory  progress 
and  the  lumbago  is  often  banished  for  years.  Occasionally 
patients  complain  that  the  pains  wander  from  the  back  to 
the  thigh  or  chest,  etc.  The  application  should  follow  up 
the  pains,  which  gradually  diminish,  disappearing  last  at  the 
place  where  they  began. 

Old  Injuries. — High  temperatures  can  nearly  always  be 
prescribed  from  the  first. 

Neuritis. — In  all  applications  to  painful  nerves  low  or 
moderate  temperatures  must  be  employed,  beginning  at 
first  as  low  as  40°  to  43-3  °C.,  and  for  ten  minutes  or  so 
only.  Each  case  must  be  judged  by  itself,  for  there  are 
few  in  which  excellent  results  are  not  obtained  if  sufficient 
care  be  taken.  Occasionally  there  are  inveterate  cases  of 
sciatica  that  show  no  signs  of  improvement,  even  after 
prolonged  applications. 

In  these  cases,  if  no  reaction  has  taken  place  after  a  few 
packings,  the  reaction  must  be  enforced.  This  is  done  by 
applying  two  or  three  packs  at  54-5°  C.  When  the  reaction 


NAUHEIM  BATHS  149 

occurs,  lower  the  temperature  to  46°  C.,  and  let  it  remain 
at  this.  As  soon  as  the  pain  lessens,  the  packs  should  be 
applied  every  other  day,  and  later  twice  a  week. 

Alcoholic  neuritis  (multiple)  may  be  successfully  treated 
with  fango. 

Abdominal  or  Pelvic  Neuroses. — High  temperatures 
are  most  useful  here.  The  whole  abdominal,  lumbar,  and 
sacral  regions  are  treated.  This  is  mostly  of  service  in 
gynaecological  patients. 

Tabes  Dorsalis. — For  the  shooting  pains,  four  or  five 
packs,  applied  every  second  day,  often  produce  a  very 
satisfactory  result.  The  pains  diminish,  and  often  dis- 
appear entirely. 

In  chronic  bronchial  catarrh,  pleuritic  effusion,  abdominal 
diseases,  gall-stone  colic,  and  pelvic  disorders,  the  highest 
temperatures  must  be  used. 

Gout. — In  acute  gout  fango  is  especially  useful;  it  allays 
the  pain  and  reduces  the  duration  of  the  attack.  After 
three  or  four  days  improvement  sets  in,  and  by  the  seventh 
day  an  excellent  result  is  nearly  always  produced,  whilst 
otherwise  the  patient  would  have  had  to  stay  in  bed  or  on 
an  easy  chair  for  three  or  four  weeks.  In  forty  cases  of 
acute  gout  we  had  only  one  where  the  effect  was  not  so 
prompt. 

Sand  Baths. — The  body,  or  a  portion  of  it,  is  immersed  in 
sand  heated  to  a  temperature  of  from  42-4°  to  54-4°  C.  Pro- 
fuse perspiration  results,  with  reddening  of  the  skin  upon 
which  the  sand  cakes. 

The  body  temperature  rises  3°  or  4°  degrees,  owing  to 
delayed  heat  loss.  These  baths  are  used  at  Harrogate 
and  at  Lavey,  in  Switzerland. 

The  sand  was  formerly  warmed  by  exposure  to  the  sun, 
but  is  now  usually  heated  in  special  ovens.  Fine  hard  sea 
or  river  sand  is  used.  The  heated  sand  is  laid  for  a  depth 
of  6  to  12  inches  on  the  bottom  of  the  tub,  and  the  patient 
lies  down  in  this.  His  head  is  raised  on  a  pillow,  and  the 
body  carefully  covered  with  warm  blankets. 

The  temperature  of  the  sand  to  begin  with  is  from  45° 
to  50°  C.,  and  may  be  maintained  by  means  of  hot  pipes 
in  the  floor  of  the  tub.  Perspiration  rapidly  occurs, 


150        MANUAL  OF  PHYSIO-THERAPEUTICS 
FANGO  TREATMENT. 


FIG.  75.  —APPLICATION  OF  THE  FANGO. 


FIG    76. —"PACKED  TTp." 


NAUHEIM  BATHS  151 

and  is  freely  absorbed  by  the  sand,  so  that  the  patient 
experiences  no  discomfort.  Pulse  and  respiration  are 
quickened. 

Duration,  one  to  one  and  a  half  hours.  The  patient 
is  treated  as  after  the  steam  cabinet  or  Turkish  bath. 

Indications. — These  baths  are  specially  indicated,  in 
preference  to  vapour  or  water  baths,  where  a  powerful 
skin  stimulation  with  increase  in  body  heat  is  desired. 
They  are  of  service  in  various  joint  affections  of  a  gouty 
or  rheumatic  nature,  in  neuralgia,  peripheral  neuritis,  and 
in  chronic  inflammatory  affections  of  the  uterus. 

They  should  not  be  given  to  patients  who  are  suffering 
from  cardiac  disease  of  an  organic  nature,  phthisis  pulmon- 
alis,  or  to  pregnant  women. 

Brine  Baths  ("  Sool-Bader  ").- — These  baths  are  prepared 
from  water  containing  sodium  chloride,  or  by  adding  saline 
to  ordinary  water.  Powders  may  be  used  which  are  prepared 
from  suitable  mineral  waters  by  concentration. 

The  salts  are  chiefly  chlorides  of  sodium,  magnesia,  and 
calcium.  From  15  to  20  pounds  are  necessary  to  make  a  full 
bath  to  contain  3  per  cent.  The  bath  water  should  con- 
tain not  less  than  1-5  per  cent,  of  saline  matter,  and  the 
amount  may  be  increased  up  to  5  or  6  per  cent.  The  usual 
temperature  of  the  bath  is  35°  C. 

The  action  of  these  baths  depends  chiefly  on  the  irritative 
effect  of  the  saline  matter  on  the  patient's  skin,  which  is 
rendered  somewhat  hyper  aesthetic.  Production  of  C02  is 
increased  and  the  blood-pressure  rises.  The  baths  possess 
a  somewhat  diuretic  action,  and  the  urea  and  chlorides 
are  excited  and  increased.  The  effect  is  greatest  if  the 
saline  percentage  of  the  bath  be  low.  With  the  increased 
metabolism  the  patient's  appetite  improves. 

Indications. — These  baths  are  of  value  in  the  treatment 
of  various  chronic  inflammatory  disorders  of  the  pelvis  in 
the  female,  such  as  perimetritis  and  parametritis,  in  chronic 
joint  rheumatism,  and  neuritis. 

Medicated  Baths. — Vegetable,  animal,  or  mineral  matter 
are  added  to  the  water  in  these  baths  in  order  to  modify  their 
action  in  various  ways.  Among  the  substances  employed 
are  dried  plants,  such  as  camomile,  thyme,  spearmint, 


152        MANUAL  OF  PHYSIO-THERAPEUTICS 

lavender,  oil  of  cade,  etc.     An  alcoholic  extract  of  these  is 
added  to  the  bath  water. 

Peat  Baths. — These  are  used  at  Buxton,  Strathpeffer, 
and  Harrogate  in  England — very  largely  at  the  latter  place, 
the  weekly  consumption  of  peat  in  the  season  being  25  tons. 
The  peat  at  Harrogate  is  obtained  from  Goole,  near  Hull, 
and  is  peculiarly  free  of  organic  matter.  The  preparing 
of  the  bath  is  rather  an  elaborate  process,  and  requires  a 
lot  of  labour,  hand  and  mechanical.  The  peat  is  first  chopped 
up  finely  and  run  into  bins  containing  sulphur  water,  brine, 


FIG.  77.— PEAT  BATH. 
(Harrogate). 

and  plain  water.  Revolving  blades  in  the  bins  further 
break  up  the  peat  and  thoroughly  mix  it  up  with  the  waters. 
It  is  then  run  through  piping  controlled  by  valves  into 
the  bath  tubs  underneath,  and  heated  there  to  the  required 
temperature  by  means  of  steam.  Evenness  of  temperature 
all  over  is  secured  by  further  careful  mixing,  and  the  tem- 
perature is  checked  in  various  parts  of  the  bath.  The  bath 
tub  is  then  run  through  from  the  preparation  chamber  into 
the  actual  bathroom  through  a  sliding  door.  The  patient 


NAUHEIM  BATHS  153 

lies  in  the  peat  mixture  for  the  prescribed  period,  varying 
with  different  cases,  but  seldom  exceeding  forty-five  minutes, 
and  then  is  roughly  swilled  down  and  put  through  a  needle 
bath  from  hot  to  cold.  He  is  then  packed  with  towels  and 
sheets  until  he  is  quite  cooled  off. 

The  bath  tub  is  run  back  out  of  the  bathing-room,  emptied, 
and  scalded  out  for  the  next  patient,  for  whom,  of  course, 
fresh  peat  has  to  be  used.  It  will  be  observed  that  the 
amount  of  haulage  and  labour  involved  is  very  considerable. 
So  popular  are  these  baths  at  Harrogate,  however,  that 
sixteen  are  in  regular  use,  and  more  are  to  be  shortly  added. 


SECTION   III 

CHAPTER  I 
MASSOTHERAPY 

MASSAGE,  or  massotherapy,  consists  in  the  treatment  of 
various  forms  of  disease  by  systematic  manipulations. 
The  derivation  of  the  word  is  from  the  Arabic  Mass'h, 
to  press  softly,  the  Sanscrit  root  being  makch.  There  is 
a  Greek  word,  [ido-aw,  meaning  to  handle  or  knead. 

Massage  is  a  very  ancient  form  of  treatment.  In  Chinese 
manuscripts  allusions  to  it  will  be  found  dating  back  to  a 
period  as  remote  as  three  thousand  years  before  the  Christian 
era,  and  there  are  oral  traditions  of  even  greater  antiquity. 
The  manuscript,  Kong  Fao,  the  date  of  which  is  3000  B.C., 
contains  detailed  accounts  of  the  various  manipulations. 
The  practice  seems  to  have  been  common  to  Celestials, 
Persians,  Greeks,  and  Romans.  Much  information  in 
regard  to  the  early  history  of  massage  is  found  among 
the  writings  of  Celsus,  Galen,  Hippocrates,  Oribasius,  and 
other  ancient  writers. 

Hippocrates  says:  "A  physician  must  be  expeiienced 
in  many  things,  but  assuredly  also  in  rubbing,  for  things 
which  have  the  same  name  have  not  always  the  same  effect ; 
for  rubbing  can  bind  a  joint  that  is  too  loose,  and  loosen  a 
joint  that  is  too  tight.  Rubbing  can  bind,  can  loosen,  can 
make  flesh,  and  can  make  parts  to  waste.  Hard  rubbing 
binds,  and  soft  loosens." 

The  Romans  frequently  employed  massage  after  their 
bath,  just  as  we  employ  the  "  shampoo  "  after  the  Turkish 
bath  at  the  present  day;  and  after  the  circus  fights  it  was 
employed  to  restore  sprained  and  stiffened  joints  to  their 
normal  flexibility  and  suppleness.  Homer  tells  how  Women 

154 


MASSOTHERAPY  155 

rubbed  and  anointed  veterans  after  the  toil  and  stress  of 
battle. 

A  few  years  ago  massage  was  so  vaunted  and  exploited 
for  commercial  reasons  that  medical  men  were  inclined  to 
regard  it  with  considerable  scepticism  and  suspicion.  It 
has,  however,  stood  the  test  of  time,  and  we  know  at  the 
present  day  that  it  is  a  reliable  and  powerful  therapeutic 
agent.  The  advertising  "rubber  "  professes  that  it  will  cure 
almost  any  ill  that  flesh  is  heir  to,  from  obesity  to  con- 
sumption; on  the  contrary,  its  sphere  of  action  is  in  most 
hands  comparatively  limited.  Carried  out  under  the 
direction  of  a  trained  and  scientific  physician,  it  may, 
however,  yield  brilliant  results  in  numerous  conditions 
obdurate  to  the  action  of  drugs. 

Some  medical  men  have  a  very  limited  and  unfortunate 
conception  of  the  process.  They  call  it  "rubbing,"  and 
think  that  any  able-bodied  and  active  man  or  woman  can 
master  the  technique  in  a  few  lessons  and  proceed  to  "  rub  " 
with  good  results.  This  is  far  from  the  truth.  Con- 
siderable training  and  aptitude  are  needed,  and  at  least  an 
elementary  knowledge  of  anatomy  is  essential.  In  the  Ling 
School,  in  Stockholm,  the  course  of  training,  which  also 
includes  medical  gymnastics,  occupies  a  period  of  five  years. 

It  must  be  admitted  that  women  are  more  skilful  and 
successful  at  massage  than  men,  especially  in  "rest  cures  "; 
their  touch  is  more  delicate,  their  hands  softer  and  more 
flexible.  There  are,  however,  unquestionable  objections  to 
the  application  of  general  massage  by  a  member  of  one  sex 
to  the  other.  Indeed,  it  is  in  connection  with  this  very 
question  that  massage  fell  some  time  ago  into  such  dis- 
repute. 

To  the  blind,  above  all,  is  granted  the  "  tactus  eruditus," 
and  in  Japan  massage  is  regarded  as  peculiarly  their  pro- 
vince. With  this  idea  they  have  been  trained  from  time 
immemorial,  and  until  recently  none  but  the  blind  were  so 
engaged.  Of  late  years,  however,  people  possessed  of  their 
sight  have  entered  the  arena,  and  the  competition  has 
become  very  keen  in  spite  of  the  low  rate  of  remunera- 
tion. 

To  acquire  a  good  knowledge  of  massage,  pupils,  having 


156        MANUAL  OF  PHYSIO-THERAPEUTICS 

gone  through  a  course  of  good  general  education,  spend 
from  three  to  five  years  in  the  schools  for  the  blind.  When 
found  to  be  an  efficient  masseur,  the  blind  student  either 
takes  a  post  in  one  of  the  schools  as  teacher,  or  starts  on  his 
own  account  as  a  private  masseur.  In  Yokohama,  with  a 
population  of  half  a  million,  there  are  no  less  than  1,000  men 
and  women  engaged  in  the  practice  of  massage,  of  whom 
900  are  blind;  400  of  these  belong  to  a  guild,  and  600  are 
working  on  their  own  occount. 

General  Rules. 

The  part  to  be  treated  should  be  placed  in  a  posture  of 
complete  repose,  with  the  muscles  quite  flaccid.  It  is 
impossible  to  apply  massage  to  muscles  in  a  state  of  active 
contraction. 

The  entire  limb  should  be  in  the  same  plane,  or  with  the 
distal  portion  somewhat  higher  than  the  proximal,  and  the 
manipulations  are  always  carried  out  in  a  centripetal  direc- 
tion, commencing  at  the  most  distal  point  and  moving 
towards  the  trunk. 

General  massage  is  conveniently  carried  out  with  the 
patient  lying  on  a  bed,  or  on  a  couch  of  27  to  30  inches  in 
height. 

While  petrissage  and  tapotement  can  be  quite  well 
performed  with  the  patient's  clothes  on,  it  is  best  to  remove 
all  clothing  and  have  the  patient  warmly  covered  with 
blankets,  except  the  actual  part  under  treatment. 

To  avoid  skin  irritation  some  oil  or  vaseline  is  sometimes 
used;  a  purified  petroleum  oil,  such  as  "Dee  oil,"  is  best; 
but  unless  the  skin  be  unusually  dry  and  hard,  they  can  all 
be  dispensed  with;  and  if  any  lubricant  be  used,  boracic 
acid  will  often  suffice.  The  better  the  masseur,  the  less 
adventitious  aid  of  this  nature  will  he  require. 

The  duration  of  the  seance  will,  of  course,  depend  on  the 
nature  of  the  case;  the  tendency  is  to  give  too  long  a  time. 
For  any  joint,  limb,  or  special  region,  ten  to  fifteen  minutes 
is  ample.  When  general  massage  is  required,  a  period  of 
thirty  to  forty  minutes  will  be  necessary;  and  in  Weir 
Mitchell  cases  up  to  one  hour  twice  daily. 


MASSOTHERAPY 


157 


While  the  methods  of  different  operators  will  vary  some- 
what, the  following  manoeuvres  are  universally  employed: 

Effleurage,  or  Stroking,  is  a  gentle  stroking  or  rolling 
of  the  skin,  gradually  increased  to  moderately  firm  friction, 
always  in  a  centripetal  direction  (Fig.  78).  In  dealing  with 
small  areas  the  palmar  surface  of  the  masseur's  fingers  are 
employed,  while  over  large  surfaces  the  whole  surface  of 
the  palm  of  the  hand  is  applied  to  the  skin.  Sometimes  the 
ulnar  edge  of  the  hand  is  employed  in  preference. 

Each  stroke  commences  from  the  most  distal  point  on 
the  extremity  under  treatment.  In  the  up-stroke  the 
pressure  applied  is  somewhat  firm,  while  in  the  down-stroke, 
which  should  be  absolutely  continuous,  less  pressure  is 
exercised.  From  start  to  finish  of  each  movement  the 


FIG.  78. — EFFLEURAGE  CARRIED  OUT  WITH  THE  FINGER-TIPS. 

hand  of  the  operator  does  not  leave  the  patient's  skin.  The 
rapidity  of  the  stroke  varies  with  the  effect  which  it  is 
desired  to  produce.  Rapid,  brisk  strokes  of  about  one 
hundred  per  minute  are  stimulating,  while  slower  and  firmer 
strokes  of  seventy  to  the  minute,  or  less,  are  soothing  in 
effect. 

P^trissage,  or  Kneading. — This  is  one  of  the  most  valu- 
able manipulations,  as  well  as  one  of  the  most  difficult 
to  carry  out  properly  (Fig.  79).  The  skin  and  muscles  are 
grasped  and  kneaded  seriatim  from  the  peripheral  parts 
to  the  centre  of  the  trunk,  the  hold  being  alternately  tight- 
ened and  loosened. 

It  is  of  the  utmost  importance  that  neither  the  skin  nor 
the  hairs  are  dragged  on,  for  this  is  very  painful  at  the 
time,  and  often  causes  a  crop  of  boils  to  form  later  which 


158         MANUAL  OF  PHYSIO-THERAPEUTICS 

will  for  the  time  being  necessitate  the  entire  suspension  of 
the  massage.  In  dealing  with  the  larger  groups  of  muscles, 
such  as  the  quadriceps  extensor  groups,  it  is  well  to  use  both 
hands  simultaneously  (Fig.  83).  It  is  sometimes  possible 


FIG.  79. — PETRISSAGE  WITH  A  SINGLE  FINGER  OR  THUMB  TO 
REMOVE  INFLAMMATORY  EXUDATES. 


in  this  way  to  deal  with  the  muscles  on  either  side  of  a  limb 
at  the  same  time,  and  roll  the  muscles  against  the  bone. 
This  special  manoeuvre  is  known  as  "fulling,"  from  its 
similarity  to  the  movements  of  the  fuller  in  linen  bleaching. 


FIG.  80. — PKTRISSAGE  OF  THE  FOREARM  WITH  BOTH  THUMBS. 

Tapotement,  or  Tapping. — This  consists  in  a  series  of 
blows  struck  in  quick  succession,  either  with  the  fingers, 
the  edge  of  the  hand,  or  the  whole  hand  (Figs.  81,  82).  The 
blow  should  be  staccato  in  character,  coming  from  the 
wrist,  rapidly  delivered  with  a  certain  rhythm.  To  pro- 


MASSOTHERAPY 


159 


duce  a  superficial  effect  the  fingers  only  are  used,  while  if 
we  wish  to  act  on  the  muscles  and  deeper-lying  structures, 
a  series  of  chopping  strokes  are  given  with  the  ulnar  edge 
of  the  hand  along  the  whole  length  of  the  muscle  in  its  trans- 
verse axis.  Bearing  in  mind  that  the  object  is  to  produce 
a  slight  mechanical  stimulus,  and  not  a  painful  impression, 
care  must  be  taken  that,  when  the  whole  hand  is  used,  what 
is  intended  to  be  a  sharp  blow  or  stroke  does  not  degenerate 
into  a  smack.  No  pain  or  bruising  should  be  produced. 
When  the  ulnar  surface  of  the  hand  is  used  (Fig.  82),  the 
fingers  should  not  touch  the  patient's  skin,  and  the  blow 


FIG.  81. — TAPOTEMENT  WITH  THE  DORSAL  SURFACE  OF  THE 

HAND. 


must  come  from  the  elbow-joint.  To  successfully  carry  out 
this  manipulation  some  delicacy  of  touch  is  requisite,  and 
also  considerable  manual  strength. 

Friction  Massage.— This  consists  in  rubbing  small  circles 
from  the  peripheral  parts  centripetally,  using  the  whole 
hand,  the  thenar  eminences,  or  the  finger-tips,  according 
to  circumstances.  It  is  of  especial  use  in  treating  joints  and 
any  region  where  kneading  is  impracticable. 

Vibration. — This  is  in  some  respects  a  combination  of 
the  two  preceding  manipulations  (Fig.  85),  a  vibratory  or 


160        MANUAL  OF  PHYSIO-THERAPEUTICS 

shaking  movement  being  added  to  them.  It  is  probably, 
of  all  the  different  massage  manipulations,  the  most  difficult 
to  acquire,  and  it  is  the  only  one  which  can  be  with  advan- 
tage carried  out  by  mechanical  means  (see  "Mechanical 
Vibration  "). 


FIG.  82. — "  HACKING  " — A  VARIETY  OF  TAPOTEMENT. 


"IG.  83. — PKTRISSAGE  OF  THE  ARM  MUSCLES  WITH  VIBRATORY 
MOVEMENT. 


MASSOTHERAPY 


161 


General  Massage. 

While  it  is  immaterial  whether  we  begin  with  a  foot  or 
with  the  upper  extremity,  it  is  well  as  a  matter  of  routine 
to  follow  a  regular  order;  for  instance,  legs,  arms,  chest, 
abdomen,  and  back. 

The  patient,  except  for  the  last-named  region,  lies  in  the 
supine  position  throughout,  with  only  so  much  of  his  body 
exposed  as  is  actually  under  manipulation. 

Massage  of  one  extremity  is  much  like  another,  so  that 
what  is  said  of  the  lower  extremity  will  in  large  measure 


FIG.  84. — EFFLEURAGE  PERFORMED  WITH  THE  ENTIRE  PALM 
OF  THE  HAND  RAPIDLY  MOVED  TOWARDS  THE  KNEE. 

apply  to  the  arms.  If  the  hair  of  the  patient's  skin  be 
long,  it  may  save  much  pain  and  trouble  to  shave  the  leg 
close,  or  at  any  rate  crop  it  with  scissors. 

If  the  left  extremity  is  to  be  manipulated,  the  masseur 
will  stand  at  the  patient's  right.  At  the  commencement 
each  toe  is  flexed  and  extended  two  or  three  times;  then 
the  ankle,  knee,  and  hip-joint,  etc.  The  patient's  left  foot 
is  taken  in  the  masseur's  left  hand,  while  with  the  right  hand 
on  the  dorsal  surface  he  strokes  towards  the  ankle.  The 
sole  of  the  foot  is  then  kneaded  with  the  fingers,  and  then 
the  skin  around  the  malleoli  and  tendo  Achillis  with  the 
thumb  and  fingers. 

In  treating  the  leg,  the  patient  lies  upon  his  right  side, 

11 


162         MANUAL  OF  PHYSIO-THERAPEUTICS 

while  the  masseur  is  seated.  Resting  the  patient's  heel  on 
his  knee  or  thigh  (Fig.  84),  a  few  steady  strokes  are  made 
upwards  from  the  level  of  the  ankles. 

The  muscles  of  the  calf  are  then  thoroughly  kneaded,  and 
then  the  muscles  on  the  anterior  aspect  of  the  leg  are  simi- 
larly dealt  with.  If  the  leg  is  large  and  fleshy,  the  more 
superficial  layers  of  muscles  are  pressed  and  kneaded  against 
the  deeper  layers  ("fulling  ");  a  little  light  effleurage  then 
quickly  concludes  the  treatment  of  this  region. 


FlG.    85. KOTATION    OF    THE    FOREARM   MUSCLES. 


After  stretching  the  skin  around  the  knee  and  applying 
a  little  friction,  the  thigh  is  dealt  with.  Effleurage  is  first 
applied  to  the  whole  thigh  and  hip.  Petrissage  is  then 
applied  to  the  large  groups  of  muscles— quadriceps  cruris 
and  adductors — both  hands  being  used  at  the  same  time. 

The  movements  must  pass  from  below  upwards.  Effleur- 
age is  used  at  the  finish  as  usual.  The  patient  lying  on 
his  right  side,  effleurage  is  then  carried  out  around  the  head 
of  the  hip-joint;  with  the  operator's  right  hand  the  short 
muscles  around  the  trochanter  arc  then  carefully  kneaded. 

In  dealing  with  the  upper  extremity,  the  hand  is  manipu- 
lated in  mn oh  the  same  manner  as  the  foot;  the  thenaj1 


MASSOTHERAPY  163 

and  hypothenar  eminences  are  thoroughly  kneaded  and 
finished  with  effleurage,  which  is  continued  up  the  forearm ; 
the  wrist,  elbow,  and  shoulder- joint  are  then  freely  flexed, 
extended,  and  circumrotated. 

Holding  the  patient's  left  hand  in  his  right,  the  operator 
thoroughly  kneads  the  muscles  of  the  forearm  on  its  anterior 
and  posterior  aspects.  Similar  treatment  is  then  carried  out 
on  the  upper  arm,  finishing  with  the  shoulder- joint. 

The  Chest.— The  pectorals  are  treated  with  kneading 
movements  and  tapotement  (sometimes),  and  effleurage 
carried  out  over  the  rest  of  the  surface  of  the  chest, 
the  posterior  surface  remaining  over  until  the  back  is 
treated. 

The  Back.  —  The  patient  having  been  comfortably 
arranged  in  the  prone  position,  friction  and  kneading  is 
applied  to  the  back  of  the  neck.  Effleurage  follows  along 
the  whole  back,  somewhat  rapid  and  vigorous  in  character. 
Thumb  and  finger  kneading  is  applied  to  the  erector  spinse 
and  deep  muscles  of  the  back,  and  following  this  the  muscles 
of  the  hips  and  buttocks  are  thoroughly  kneaded.  Rapid 
effleurage  of  the  whole  surface  of  the  back  is  now  performed, 
with  very  quick  stroking  of  the  skin  over  the  spine,  which 
becomes  reddened. 

Massage  of  the  Stomach. — The  object  of  gastric  mas- 
sage is  twofold — viz.,  to  increase  the  motilityor  contractile 
power  of  that  organ  in  atonic  conditions,  and  at  the  same 
time  increase  the  quantity  and  quality  of  the  secretion. 
Massage,  properly  carried  out,  will  always  increase  the 
acidity  of  the  gastric  juice,  except  when  the  absence  of 
hydrochloric  acid  is  due  to  malignant  disease.  The  gastric 
tenderness  often  present  in  hyperchlorhydria  will  often 
prevent  the  performance  of  gastric  massage,  and  this  is  well, 
seeing  the  condition  would  for  the  most  part  be  aggravated 
by  such  manipulation.  In  all  cases  of  diminished  acidity, 
however,  massage  is  helpful. 

To  reach  the  comparatively  limited  area  of  the  stomach 
wall  that  is  accessible  to  touch,  in  the  first  place  the  patient 
must  be  thoroughly  relaxed,  and  deep  manipulations  be 
used  (Fig.  86).  Any  rigidity  of  the  abdominal  muscles  will 
make  the  manipulation  impossible.  If  relaxation  cannot 


164         MANUAL  OF  PHYSIO-THERAPEUTICS 

be  obtained  with  the  patient  in  the  usual  supine  position, 
with  raised  head  and  drawn-up  knees,  he  should  be  asked  to 
turn  on  his  right  side,  and  the  masseur  work  from  behind 
him. 

Deep  kneading  and  shaking,  followed  occasionally  by 
vibration  and  slapping,  are  the  movements  most  commonly 
employed.  The  seance  usually  lasts  ten  minutes,  and  the 
treatment  is  well  given  about  half  an  hour  after  food. 

In  cases  of  atony  and  defective  motility,  when  it  is 
desired  to  aid  the  removal  of  the  gastric  contents  through 


TIG.  86. — MASSAGE  OF  THE  STOMACH. 


the  pylorus,  after  preliminary  effleurage  and  kneading,  the 
masseur  should  stroke  firmly  from  left  to  right  across  the 
stomach  with  the  whole  surface  of  the  right  hand,  getting 
the  thenar  eminence  well  in  under  the  left  ribs,  and  then 
slowly  moving  across  in  a  somewhat  downward  direction. 
It  is  possible  in  a  few  minutes  to  get  rid  of  a  large  amount 
of  food  debris  through  the  pylorus  by  means  of  this  move- 
ment if  efficiently  carried  out. 

Massage  of  the  stomach  is  too  often  superficial,  and  the 
defectively  trained  masseur  soon  reveals  himself  by  rubbing 
in  the  wrong  direction. 


MASSOTHERAPY 


165 


Massage  of  the  Abdomen. — Before  commencing,  the 
patient  should  always  see  that  the  bladder  is  empty,  and  if 
possible  an  action  of  the  bowels  should  be  obtained. 

In  order  to  get  the  muscles  completely  relaxed,  the 
patient's  head  and  shoulders  are  elevated,  his  knees  flexed, 
and  a  request  made  that  he  breathe  deeply  and  regularly. 
The  greatest  difficulty  is  met  with  in  getting  the  proper 
degree  of  relaxation  in  nervous  individuals,  particularly 
women.  A  little  patience,  and  chatty  conversation  to 
distract  the  patient's  mind,  will  generally  overcome  this 
difficulty  after  a  few  minutes. 


FIG.  87.-  —  MASSAGE  OF  THE  ABDOMEN. 


In  commencing,  the  masseur  puts  both  his  hands  under- 
neath the  patient  (Fig.  87)  until  they  meet  in  the  lumbar 
region,  and  then  draws  the  hands  forwards,  compressing  the 
patient's  flanks,  and  at  the  same  time  lifting  somewhat 
until  the  hands  again  meet  in  the  mid-line  of  the  abdomen. 

Deep  kneading  is  begun  on  the  right  iliac  space  with  both 
hands,  and  the  entire  abdomen  is  thoroughly  kneaded 
several  times  from  the  right  to  the  left  side.  The  left  iliac 
space  is  treated  in  the  same  way,  and  the  colon  is  followed 
throughout  its  entire  course  (Fig.  88)  and  treated  with 
digital  kneading.  More  general  and  heavier  manipulation 


166        MANUAL  OF  PHYSIO-THERAPEUTICS 

may  be  carried  out  with  the  thenar  eminence  and  fist  in 
patients  who  are  tolerant  of  such  manipulation.  The 
concluding  movement  is  light  pressure  of  the  abdomen  with 
the  whole  of  the  operator's  hand,  to  which  he  then  imparts 
a  vibratory  movement. 

A  very  poor  substitute  for  good  abdominal  massage  is 
the  shot  bag — a  stout  canvas  bag  containing  small  shot — 
which  is  moved  about  the  abdomen,  over  the  course  of  the 
colon,  etc.,  by  the  patient  himself.  A  similar  appliance  is 


FIG. 


-MASSAGE  OF  THE  ABDOMEN  FOLLOWING  THE  COURSE 
OF  THE  COLON. 


Sahli's  iron  ball.  Such  massage  is,  of  course,  elementary  in 
the  extreme ;  but  in  cases  of  constipation,  where  the  genuine 
article  is  not  available,  either  from  expense  or  other  reason, 
these  manipulations  are  sometimes  of  service. 

The  General  Effects  of  Massage.- -After  the  conclusion 
of  each  seance  the  patient  should  be  warmly  covered  up 
and  allowed  to  rest  for  upwards  of  half  an  hour. 

A  sense  of  drowsiness  is  often  experienced,  and  the 
patient  may  fall  asleep.  In  a  few  days  he  will  find  his 
appetite  improving,  his  sleep  to  be  sounder,  and  his  general 
condition  improved.  The  skin  becomes  softer,  more  elastic 
and  glossy,  and  fresher  in  colour.  The  veins  are  more 
distinct,  and  there  is  finally  improved  tactile  sensation, 


MASSOTHERAPY  167 

although  the  immediate  effect  of  massage  is  to  somewhat 
deaden  sensation.  Von  Mosengeil  demonstrated  by  inject- 
ing solutions  of  Indian  ink  into  rabbits'  joints  that  the 
rapidity  of  absorption  was  much  increased  by  massage. 
He  applied  massage  to  one  side,  and  not  to  the  other, 
and  found  that  on  the  treated  side  the  lymphatic  glands 
in  the  vicinity  of  the  joint  were  soon  full  of  particles  of 
Indian  ink. 

The  muscular  tone  is  more  rapidly  restored  after  fatigue 
by  massage  than  by  mere  resting,  and  the  muscles  respond 
more  readily  to  electrical  stimuli.  Waste  and  fatigue 
products  are  removed  from  the  muscle  tissue,  and  new 
nourishment  introduced,  and  the  patient  soon  puts  on  weight 
owing  to  the  increased  nitrogenous  metabolism. 

The  force  of  the  cardiac  systole  is  increased  by  massage 
of  the  limbs,  and  the  blood-pressure  raised.  On  the  other 
hand,  abdominal  massage  tends  to  some  degree  of  vascular 
hypotonicity  and  generally  lowered  blood-pressure.  The 
respirations  are  increased  in  both  depth  and  frequency. 
The  red  blood-corpuscles  are  notably  increased,  both  in 
the  healthy  person  and  in  the  anemic,  after  a  course  of 
massage;  there  is  not,  however,  a  proportionate  increase 
in  the  amount  of  hemoglobin.  Both  the  peristalsis  of  the 
stomach  and  its  secretory  power  are  markedly  stimulated 
by  local  massage.  Intestinal  peristalsis  is  also  increased, 
while  the  activity  of  the  liver  is  similarly  affected. 

The  temperature  of  the  whole  body  is  temporarily  raised 
about  1°  C.,  but  rapidly  returns  to  the  normal. 

THERAPEUTIC  INDICATIONS. — Dyspepsia  and  Constipation 
are  frequently  markedly  relieved  by  judicious  massage. 
In  the  former  condition  it  is  of  special  importance  to  see  that 
the  massage  is  not  out  of  proportion  to  the  amount  of  food 
which  the  patient  is  taking — and  assimilating.  If  caution  be 
not  observed,  weight  loss  is  easily  increased.  As  the  appe- 
tite improves  more  food  is  consumed,  and  with  improved 
assimilation  the  duration  of  massage  can  be  slowly  increased. 

In  constipation  the  massage  should  be  applied  in  the 
early  morning  before  the  patient  dresses,  so  as  to  induce  a 
healthy  action  of  the  bowels  at  the  usual  time.  Both  the 
abdominal  muscles  and  the  intestinal  wall  should  be  in- 


168        MANUAL  OF  PHYSIO-THERAPEUTICS 

fluenced.  Beginning  in  the  region  of  the  caecum,  the 
operator  should  work  up  the  right  side  of  the  abdomen, 
along  the  transverse  colon,  just  above  the  level  of  the 
umbilicus,  and  down  the  left  side  (see  Fig.  86). 

After  superficial  movements  have  been  performed,  the 
pressure  should  be  increased,  and  the  hands  given  a  rotatory 
motion  and  made  to  follow  the  line  of  the  colon. 

The  abdomen  should  be  so  treated  for  about  fifteen 
minutes  daily,  and  the  treatments  kept  up  for  a  month  or 
six  weeks,  according  to  results.  The  movements  can  later 
be  imitated  by  the  patient  himself  by  means  of  the  "shot- 
bag,"  though,  of  course,  this  is  much  inferior  to  manual 
treatment. 

Insomnia  is  commonly  greatly  benefited  by  general  and 
abdominal  massage,  which  should,  however,  be  applied 
late  in  the  day. 

Joint  Affections. — Various  sprains  and  synovia!  inflam- 
matory conditions  are  much  improved  by  massage.  The 
most  striking  results  are  seen  in  cases  where  the  joint  has 
become  stiff  and  useless  from  disuse,  and  the  muscles 
atrophied.  In  these  cases  initial  breaking  down  under  an 
anaesthetic  is  often  required.  Chronic  rheumatoid  arthritis, 
while  somewhat  helped,  is  less  yielding  to  the  application 
of  massage  than  gout  or  gonorrhceal  rheumatism. 

In  these  conditions  active  treatment  for  ten  to  fifteen 
minutes  twice  daily  should  be  kept  up,  combined  with 
various  hydrotherapeutic  applications. 

Generally  speaking,  acute  inflammatory  joint  conditions 
are  best  left  alone  by  the  masseur.  At  the  same  time,  in 
acute  cases  gentle  manipulation  may  be  begun  very  early 
after  the  injury. 

Nervous  Affections  and  Myalgia. — In  obstinate  sciatica 
local  massage  may  be  of  great  service;  an  initial  "dry 
stretching  "  is  often  indicated,  then  kneading  of  the  muscles 
and  skin  stroking. 

Other  forms  of  neuritis  are  equally  benefited.  Rheumatic 
and  gouty  myalgia,  lumbago,  etc.,  frequently  yield  in  a  few 
days  to  this  mode  of  treatment.  In  regard  to  the  muscles, 
it  must  also  be  borne  in  mind  that  when  a  patient  has  been 
compelled  to  keep  his  bed  for  some  weeks,  owing  to  a  fracture 


MASSOTHERAPY  169 

or  some  illness,  convalescence  and  ability  to  walk  are  much 
helped  by  applying  massage  to  the  limbs  a  week  or  ten  days 
prior  to  getting  up. 

Other  conditions  in  which  massage  is  indicated  are  anaemia, 
obesity,  drug  habit,  chorea,  and  neurasthenia. 

Local  manipulation  of  the  uterus,  etc.,  in  subinvolution 
and  similar  conditions,  is  essentially  objectionable — nay> 
disgusting — when  performed  by  physician  or  masseur; 
hardly  less  so  when  carried  out  by  a  masseuse. 

CONDITIONS  NOT  BENEFITED  BY  MASSAGE. — The  indis- 
criminate use  of  massage  is  to  be  strongly  condemned,  for 
there  are  numerous  conditions  for  which  it  is  perfectly 
useless,  and  not  a  few  when  it  is  absolutely  hurtful  and  even 
dangerous.  Instances  of  the  latter  are,  in  general  massage, 
venous  thrombosis,  and  in  abdominal  massage,  severe 
gastric  ulcer. 

In  febrile  conditions  the  temperature  is  further  raised; 
in  acute  renal  disease  or  pulmonary  tuberculosis  it  may 
induce  a  haemorrhage.  It  may,  however,  be  employed  in 
phthisis  during  a  quiescent  period.  Abdominal  massage 
should  never  be  employed  when  the  patient  is  menstruating 
or  pregnant. 

Common  sense  will  negative  the  use  of  massage  where 
there  is  any  considerable  solution  of  continuity  in  the  skin 
of  the  patient,  be  the  immediate  cause  a  burn,  an  ulcer,  or 
a  cut.  In  any  dermatitis,  of  course,  harm  will  be  done  and 
the  condition  be  aggravated  by  massage. 

Vibration. 

Vibration  may  be  done  by  the  hand  or  mechanically. 
Probably  hand  vibration  is  about  the  most  difficult  move- 
ment to  carry  out  effectively,  and  requires  very  consider- 
able skill  and  training.  Long  practice  is  required  to  attain 
any  degree  of  speed,  and  it  is  necessary  for  the  operator  tc 
be  trained  how  to  breathe  when  doing  it;  otherwise  he  is 
inclined  to  hold  his  breath  and  exhaust  himself  very  quickly. 
Practice  is  best  carried  out  by  placing  the  tips  of  the  fingers 
on  a  table  of  moderate  size  in  the  middle  of  which  a  glass  of 
water  has  been  placed.  If  the  vibrations  are  practised 


170        MANUAL  OF  PHYSIO-THERAPEUTICS 

properly,  the  waves  of  the  water  run  towards  the  surface  of 
the  glass;  if  they  are  clumsily  performed,  the  water  will 
sway  from  side  to  side  in  a  mass. 

Practice  should  be  carried  out  daily,  or  the  masseur  loses 
his  skill;  but  too  long  spells  must  not  betaken,  or  a  sort  of 
occupation  spasm  comes  on  similar  to  writer's  cramp.  It 
is  equally  difficult  to  cure. 

With  all  the  necessity  for  training  and  the  risk  of  overuse, 
it  is  not  to  be  wondered  at  that  mechanical  vibrators  have 
largely  taken  the  place  of  manual  treatment.  The  most 
expert  masseur  cannot  exceed  600  vibrations  per  minute, 
and  the  number  quickly  falls  after  the  first  minute  to  300  or 
even  200.  Mechanical  vibration  is  by  no  means  of  recent 
origin,  as  it  was  used  by  Ling  and  also  Georgi  in  the  "  trem- 
bling movements."  Liedbeck  and  Granville  both  introduced 
a  vibrator  driven  by  mechanical  power,  and  Ewer  a  per- 
cussor  of  similar  type.  More  recently  we  have  all  heard  of 
the  Veedee  and  the  quack  Macara  vibrator,  worked  very 
much  like  an  egg-switch.  Ewer's  was  worked  by  a  foot 
pedal  like  a  dentist's  drill. 

Electricity  has  made  a  great  change  in  such  apparatus, 
hand-power  being  entirely  dispensed  with.  In  1898  Otto 
Billmaier  invented  a  very  excellent  type  of  instrument, 
one  of  which  we  possess,  rather  worn  out,  and  unfortunately 
have  been  unable  to  replace,  as  we  consider  it  the  best  vibra- 
tor yet  introduced.  It  consists  of  a  hand-piece  connected 
by  means  of  a  cable  to  an  electric  motor.  The  vibrations 
are  produced  by  means  of  a  revolving  eccentric— a  hammer 
in  the  hand-piece  on  which  is  a  sliding  adjustment  which 
regulates  the  height  of  the  strike  of  the  hammer  from  zero 
to  1  centimetre. 

No  rheostat  is  said  to  be  necessary  in  using  this  machine. 
The  power  may  be  derived  from  a  110  volt  circuit — direct 
or  alternating — or  from  a  storage  battery.  The  motor  may 
be  suspended  from  a  wall  or  ceiling,  or  supported  on  a  special 
stand  with  a  heavy  immobile  base. 

A  pulsator  vibrator  is  provided  with  the  multostat  or 

universal  apparatus,  and  is  quite  effective.     The  vibratodes 

are  usually  two  rubber  balls  and  a  round  disc  with  a  bevel. 

The  Barker  vibrator  is  a  very  well  known  one,  and  is  quite 


MASSOTHERAPY 


171 


PIG.  89. — VIBRATOR  APPLICATORS. 


BB,  Bristle  brush  applicator  for  the  head;  44,  softest  rubber  with 
thin  points;  54,  soft  rubber  with  thick  points;  56,  harder,  stiffer 
rubber  with  thick  points,  principally  for  the  head;  same  as  54, 
but  smaller  in  diameter;  same  grade  of  rubber,  as  It  is  smaller 
and  thinner;  70,  soft,  red  sponge  rubber  for  face  and  head,  and 
other  light  and  gentle  uses;  A,  for  spinal  application,  also  for 
external  rectum  treatment  ;  O,  flat,  soft  rubber  applicator  ; 
T,  for  nose  and  ear,  and  used  on  children  to  reach  interna 
organs  through  external  openings  ;  K,  flexible  back,  sold  only 
to  replace  worn-out  part  of  flexible  back  applicators;  E,  flat, 
hard  rubber  body  applicator  for  deep  local  work  ;  I,  large 
aplicator  with  flexible  back  for  deep  and  general  work;  H,  large 
applicator  with  flexible  back,  excellent  for  deep  and  general 
work,  also  when  quick  reaction  is  desired  ;  we  specially  recom- 
mend H  as  most  generally  efficient  for  body  work;  J,  most 
severe  applicator,  with  flexible  back;  VW,  very  soft  and  pliable 
applicator  for  rectal  use;  U,  same  applicator  as  V,  but  of  stiffer 
rubber;  X,  hard  rubber  rectal  dilator  with  flexible  back  for  use 
after  applicators  V  or  W ;  Y,  hard  rubber  rectal  dilator  with 
flexible  back  for  use  after  applicator  X;  Z,  hard  rubber  rectal 
dilator  with  flexible  back  for  use  after  applicator  T  ;  M,  round 
hard  rubber  for  deep  local  work. 


172        MANUAL  OF  PHYSIO -THERAPEUTICS 

effective,  a  great  variety  of  vibratodes  being  provided  with 
it.  Smaller  and  less  powerful,  but  effective  for  purely  local 
affections,  is  the  Victory.  This  is  quite  portable  and  inex- 
pensive. 

The  Effect  of  Vibration. — This  will  vary  with  the  amount 
of  force  used  and  the  rapidity  of  the  vibrations.  It  is  used 
in  a  great  variety  of  disorders — headache,  earache,  neuralgia, 
and  neuritis.  One  of  the  most  effectual  ways  of  combating 
a  sluggish  liver  is  five  to  ten  minutes'  vibration  over  the 
hepatic  region,  which  is  equal  to  at  least  an  hour's  horse 
exercise.  It  is  excellent  where  there  is  a  tendency  to  jaun- 
dice and  pale  stools  with  dark-coloured  urine. 

In  the  various  myalgias  and  muscular  rheumatism  relief 
of  pain  is  quickly  brought  by  vibration  along  with  heat 
treatment. 


CHAPTER  II 


Manipulative  Movements. 

WE  employ  these  as  a  sequel  to  or  combined  with  massage. 
Movements  may  be  active  or  passive. 

1.  Passive  Movements. — This  is  sometimes  called  a 
relaxed  movement,  the  idea  being  that  the  patient  should  en- 
deavour to  attain  the  highest  degree  of  relaxation  while  the 
masseur  imitates  the  movements  normally  performed  by  the 
patient's  own  muscles.  Many  masseurs  make  the  mistake 
of  carrying  out  from  the  start  too  wide  a  range  of  movements. 
He  should  begin  with  minor  movements,  and  gradually 
increase  them.  The  patient's  co-operation  must  be  en- 
listed, and  he  must  neither  assist  or  resist  the  manoeuvres 
which  are  carried  out;  he  should,  in  short,  be  "as  clay  in 
the  hands  of  the  potter." 

Complete  relaxation  is  not  easy  of  attainment.  We  know- 
that  in  manipulating  an  injured  joint  to  break  down  adhe- 
sions and  the  like  the  muscles  unconsciously  resist  the  move- 
ments made  by  the  operator,  and  chloroform  is  sometimes 
needed,  as  it  is  in  the  reduction  of  dislocations. 

We  probably  attain  the  highest  degree  of  relaxation  in 
sleep,  but  as  we  cannot  put  our  patients  to  sleep  for  passive 
manipulation,  and  should  quickly  wake  them  if  we  did,  the 
only  means  we  have  is  to  make  them  as  comfortable  as  pos- 
sible, getting  them  adjusted  into  attitudes  of  complete  rest- 
fulness.  If  we  disturb  this,  then  the  patient's  muscles  will 
act  in  one  way  or  another,  so  that  we  must  take  precautions 
to  support  the  part  manipulated  when  it  is  moved  from  one 
position  to  another. 

173 


174         MANUAL  OF  PHYSIO-THERAPEUTICS 

It  is  also  vital  for  the  manipulator  to  carry  out  the  move- 
ment in  just  the  same  direction  and  on  the  same  lines  as 
the  patient  would  if  doing  it  of  his  free  will. 

Certain  combinations  of  movement  are  best  carried  out  at 
the  same  time.  We  flex  the  fingers  along  with  extension 
of  the  wrist,  and  extend  the  fingers  with  flexion  of  the  wrist. 
The  wrist  is  extended  with  pronation  of  the  forearm,  and 
flexed  with  the  forearm  midway  between  pronation  and 
supination. 

Supination  of  the  forearm  is  combined  with  flexion  of  the 
elbow,  and  pronation  with  its  extension;  flexion  of  the  fore- 
arm is  most  easily  performed  if  the  elbow  is  pressed  back  at 
the  same  time. 

Abduction  of  the  arm  is  combined  with  flexion  of  the  elbow, 
while  during  adduction  the  elbow  should  be  extended. 

As  regards  the  lower  extremity,  flexion  of  the  toes  should 
be  combined  with  flexion  of  the  ankle,  and  extension  of  the 
toes  with  plantar  flexion ;  this  latter,  again,  calls  for  extension 
of  the  knee,  though  the  knee  be  kept  slightly  flexed,  even 
when  the  ankle  movement  is  at  its  extremity.  Dorsiflexion 
requires  increasing  flexion  of  the  knee.  This,  again,  must  be 
combined  with  flexion  of  the  hip,  and  extension  of  the  knee 
with  hip  extension. 

The  hip  is  best  adducted  and  abducted  with  the  knee  and 
ankle  semiflexed,  while  rotation  requires  alternate  flexion 
and  extension  of  the  knee,  flexion  accompanying  that  part 
of  the  movement  when  the  hip  is  most  flexed,  and  extension 
of  the  knee  the  part  when  the  hip  is  most  extended. 

Movements  of  the  metacarpals  and  metatarsals  are  im- 
portant, as  they  are  often  affected  with  chronic  rheumatic 
or  slight  rheumatoid  trouble  in  people  getting  past  middle 
life,  which  interferes  with  writing  and  weakens  the  grip, 
or  may  cause  lameness  when  it  is  a  question  of  the  meta- 
tarsals. 

The  great  objective  in  passive  movements  is  to  maintain 
suppleness  and  prevent  the  formation  of  contractures  and 
adhesions,  and  to  effect  this  painlessly.  This  can  only  be 
effected  by  the  use  of  skill  and  caution. 

Festina  lente  should  be  the  motto,  and  if  the  range  of 
movement  is  at  first  disappointingly  small  and  almost 


MANIPULATIVE  TREATMENT  175 

negligible,    it   will   with    care    and   perseverance    increase 
to  the  satisfaction  of  patient  and  operator  alike. 

2.  Active  Movements.— Mennell  divides  these  into— 
(1)  Free;  (2)  Assistive;  and  (3)  Resistive. 

(1)  Free  Movement. — If  a  movement  is  performed  against 
gravity,   it  is  performed  against  resistance.     Movements, 
on  the  other  hand,  of  abduction  and  adduction  with  a  weight 
and  pulley  apparatus  are  free,  owing  to  the  weight  of  the 
limb  being  counterpoised. 

The  division  between  free  and  assistive  movements  is  a 
fine  and  almost  arbitrary  one,  however. 

Free  movements  of  the  fingers  are  best  performed  with  the 
hand  resting  on  its  ulnar  border,  the  forearm  being  held 
midway  between  pronation  and  supination.  To  perform 
free  flexion  and  extension  of  the  wrist  the  forearm  should 
be  supported  in  this  position,  with  the  hand  hanging 
free. 

In  the  same  way  we  carry  out  free  rotation.  Free  flexion 
and  extension  is  best  performed  with  the  patient  recumbent, 
the  back  of  the  arm  and  the  elbow  being  fully  supported 
and  the  hand  moved  up  and  down  the  chest. 

As  regards  the  lower  extremity,  free  movements  of  the 
ankle  and  toes  may  be  carried  out  with  the  leg  hanging 
over  a  bench  or  couch. 

Free  movement  of  the  hip  or  knee  cannot  be  effected  with- 
out some  assistance,  manual  or  mechanical. 

Considerable  assistance  to  the  carrying  out  of  free  move- 
ment is  afforded  by  the  use  of  the  whirlpool  bath  described 
on  p.  110.  In  this  the  water  affords  a  certain  amount  of 
support,  and  the  warm  water  removes  the  element  of  stiff- 
ness in  large  degree. 

(2)  Assistive  Movements. — Here  in  each  movement  there 
is  a  certain  amount  of  manual  assistance,  which  has  the 
object  of  enabling  the  patient  to  do  more  than  he  otherwise 
could  unaided,  and  so  "get  him  on."     It  is  in  a  measure 
educative. 

A  principle  of  the  greatest  importance  that  has  to  be 
borne  in  mind  in  work  of  this  character  is  that,  if  one 
muscle  contracts  in  order  to  move  a  joint,  some  other  muscle 
or  group  of  muscles  must  relax, 


176         MANUAL  OF  PHYSIO-THERAPEUTICS 

It  is  often  necessary  to  combine  passive  movements  with 
assistive  movements;  that  is  to  say,  while  a  patient  may 
be  sufficiently  well  to  use  one  set  of  muscles  in  a  limb, 
as  regards  other  movements  we  have  to  give  him  such  help 
as  to  render  the  movement  passive.  Later  the  patient  may 
endeavour  to  imitate,  arid  the  assistive  movement  gradually 
takes  the  place  of  the  passive  one. 

If  a  movement  causes  a  tremor  of  coarse  character  in  the 
muscle  or  muscles  contracting,  it  should  not  be  continued. 
The  movement  should  be  first  carried  out  passively,  and  then 
the  patient  allowed  to  assist. 

(3)  Resistive  Exercises. — These  are  of  two  kinds — eccen- 
tric and  concentric.  In  the  first  the  worker  supplies  the 
resistance  and  performs  a  movement,  while  the  patient 
resists.  In  the  latter  the  patient  performs  the  movement, 
while  the  worker  resists. 

In  recovery  from  paralysis  care  should  be  exercised  in 
employing  eccentric  movements,  and  the  stretching  of 
muscular  fibres  must  always  be  avoided. 

Mechanotherapy,  or  Treatment  by  Mechanical  Means. 

The  Zander  machines  have  rather  waned  in  popularity 
with  a  tendency  to  substitute  manual  manipulation  for  the 
power-driven  Zander  machines,  with  which  occasionally 
unfortunate  accidents  occurred,  with  unfavourable  results. 
The  type  of  machine  now  employed  is  the  Borderel  Zander, 
or  activo-passive.  We  shall  deal  below  with  twelve  of  the 
best-known  and  commonly  used  types  of  machine,  as  used 
in  the  Mechano-Therapeutic  Department,  at  Harrogate. 

1.  Circumduction  of  the  Arm. — Place  the  patient  sideways 
against  the  fork  on  which  the  armpit  must  rest.     The  seat 
is  raised  or  lowered  until  the  fork  touches  the  fold  of  the 
armpit.     The  patient  grasps  the  movable  handle  with  the 
arm  fully  extended,  and  turns  the  sector.     The  axle  around 
which  the  movement  is  made  is  movable,  so  that  it  can  take 
varying  degrees  of  inclination. 

2.  Active  and  Forced  Rotation  of  the  Arm. — The  patient 
sits  down  beside  the  apparatus  and  places  the  forearm  on  the 
wooden  lever.     He  grasps  the  handle  and  leans  the  elbow 


177 

against  the  iron  ledge  attached  to  the  fixed  end  of  the  lever. 
The  patient  should  be  careful  to  keep  the  arm  vertical  and 
prevent  false  movements  of  the  body.  The  other  arm  should 


FlG.    90. ClRCUMDUCTION    OF  ARM. 


FIG    91. — KOTATION  OF  ARM. 


12 


178         MANUAL  OF  PHYSIO-THERAPEUTICS 

be  fastened  to  the  upright  with  a  strap.  The  wooden  scale 
is  loaded  with  one  or  more  flat  weights,  and  the  forearm 
gives  slowly  to  the  pull  of  the  weights. 

3.  Lowering  of  the  Arms  with  Flexion  of  the  Forearms.— 
This  exercise  deals  with  the  lowering  of  the  upstretched 
arms  by  bending  the  forearm  against  the  upper  arm.  Place 
the  patient  beneath  the  suspended  handles,  which  must  be  on 


FIG.  92. 

a  level  with  the  shoulders.  He  must  grasp  them,  and  give 
slowly  to  the  action  of  the  weights,  which  draw  the  arms 
upwards.  Then  he  lowers  his  arms  until  his  hands  are  on  a 
level  with  his  shoulders,  and  again  yields  to  the  pull  of  the 
weights. 

4.  Flexion  and  Extension  of  the  Wrists — Flexion. — The 
wrist  must  be  placed  slanting  upwards,  with  the  long  part 
of  the  lever  below  and  the  short  above. 


MANIPULATIVE  TREATMENT 


179 


Flexion  of  the  Left  Hand. — The  screw  of  the  attachment 
must  be  fixed  to  the  letters  F,  G. 

Flexion  of  the  Right  Hand. — The  screw  of  the  attachment 
must  be  fixed  to  the  letters  F,  D. 

Extension. — The  patient's  wrists  must  be  slanted  vertically 
downwards.  To  carry  out  the  active  movements,  place  one 
weight  at  the  end  of  the  short  part  of'the  lever  and  the  other 


FIG.  93. 

weight  on  the  long  part  at  a  distance  corresponding  to  the 
resistance  required.  To  carry  out  the  pendulum  (swinging) 
movement,  place  both  weights  at  the  end  of  the  long  part  of 
the  lever. 

5.  Flexion  and  Extension  of  the  Forearm. — The  patient  is 
placed  beside  the  apparatus,  and  the  arm  to  be  exercised  is 
fastened  with  the  straps  of  the  supports. 

The  elbow  must  rest  in  the  axle  of  the  lever.  By  means 
of  planks  placed  beneath  their  feet  patients  who  are  below 


180         MANUAL  OF  PHYSIO-THERAPEUTICS 

the  middle  height  can  raise  their  elbows  to  the   heights 
required. 

The  handle  is  grasped  with  the  palms  turned  upwards. 
In  the  flexion  movement  the  handle  must  be  down,  and  the 
counterweight  on  the  half  of  the  double  lever  which  is  in 
front  of  the  patient.  In  the  extension  movement  the  handle 
must  be  up,  and  the  counterweight  on  the  half  of  the  double 


FIG.  94. 

lever  which  is  behind  the  patient.  In  order  to  pass  from 
flexion  to  extension  it  is  enough  to  change  the  weights 
from  one  half  to  the  other  of  the  double  lever.  When  it  is 
a  question  of  exercising  a  left  arm  after  a  right  arm,  or  vice 
versa,  the  position  of  the  hand  lever  on  its  post  must  be 
changed  by  passing  the  rundle  provided  with  clutches. 
This  manoeuvre  forces  out  the  screw  rings  which  hold  back 
the  lever,  which  turns  180  per  cent,  around  its  axis. 


181 

6.  Pronation  and  Supination  of  the  Forearm  (Active  and 
Passive-Active ). — The  handle  of  the  apparatus  is  placed  in 
a  horizontal  position  for  the  pronation,  and  in  a  vertical 
position  for  the  supination.  The  double  lever  must  in  both 
cases  be  in  a  vertical  position  and  the  counterweights  be- 
neath. At  the  outset  of  movement  of  pronation  the  back 
of  the  hand  is  turned  downwards  with  the  thumb  behind. 
At  the  outset  of  the  movement  of  supination  the  back 


FIG.  95. 

of  the  hand  is  turned  forward  with  the  thumb  downwards. 
The  arm  must  be  held  firmly  outstretched.  To  carry  out 
the  active  movement,  one  weight  must  be  placed  in  the 
centre  of  the  lever  and  the  other  at  a  distance  from  the 
centre  which  corresponds  to  the  resistance  which  is  required 
to  be  overcome. 

The  movements  may  have  another  purpose  than  that  of 
exercising  rotatory  muscles  of  the  arms.  It  may  tend  to  pro- 
duce suppleness  by  extension  of  the  rotatory  muscles  of  the 
tendons  and  ligaments  of  the  arm.  In  this  case  a  weight  is 
placed  at  each  end  of  the  lever,  and  there  is  no  need  for 
concern  after  the  position  of  the  handle  and  the  lever. 


182        MANUAL  OF  PHYSIO-THERAPEUTICS 

7.  Cireumduetion  of  the  Hand. — The  patient  should  sit 
down  on  a  chair  beside  the  apparatus,  and  at  a  sufficient 
distance  from  it  to  allow  the  forearm  (which  is  fixed  by  a 
strap  to  the  table)  to  be  kept  in  a  straight  line  to  the  axis 
of  the  wheel.  He  should  grasp  the  handle  and  perform  a 
movement  of  circumduction  with  the  hand. 

The  degree  of  movement  can  be  increased  or  decreased  by 
fastening  the  fixed  end  of  the  handle  at  a  greater  or  less  dis- 
tance from  the  axis  of  the  wheel. 


FIG.  96. 

8.  Flexion  and  Extension  of  the  Fingers. — This  apparatus 
permits  of  the  execution  of  active  and  passive  extension 
and  flexion  movements  of  the  fingers,  and  also  of  a  pendulum 
(swinging)  movement  which  constitutes  something  midway 
between  active  and  passive  movements. 

The  ends  of  the  fingers  are  placed  between  two  padded  iron 
plates  and  the  screws  tightened.  The  patient  grasps  the 
upper  part  of  the  iron  frame.  The  oscillatory  movement 
forced  on  him  causes  the  flexion  and  extension  of  the  fingers. 

To  carry  out  the  passive  movement,  the  screw  of  the 
attachment  of  the  lever  is  loosened.  To  carry  out  the  pendu- 
lum movement,  fix  the  weight  to  the  end  of  the  long  part 


MANIPULATIVE  TREATMENT 


183 


of  the  lever  and  tighten  the  screw  of  the  attachment  to  the 
required  degree — that  is,  to  the  front  which  corresponds 
to  the  limit  of  the  movement  to  which  the  patient  can 
attain. 

To  carry  out  the  active  movement,  shift  the  weight  to- 
wards the  centre  of  the  lever  and  tighten  the  screw  of  attach- 
ment on  the  iron  plate  to  the  highest  position  of  flexion  or 
extension  of  the  hand,  the  lever  being  vertical. 


FIG.  97. 

9.  Extension  of  the  Thigh  and  Leg. — This  deals  with  a 
simultaneous  extension  of  the  articulation  of  the  thigh  and 
leg. 

The  patient  should  stand  before  the  apparatus  and  place 
his  hand  on  the  wooden  uprights.  He  must  place  the  foot 
on  the  iron  pedal,  which  is  controlled  close  to  the  ground  by 
a  catch.  On  placing  the  foot  on  this  pedal,  the  "  Debrayage" 
is  started  and  an  upward  movement  results,  to  which  the 
limb  gradually  yields. 

To  terminate  the  exercise,  the  catch  must  be  applied  to 
the  arm  of  the  lever  and  the  pedal. 


184        MANUAL  OF  PHYSIO-THERAPEUTICS 

10.  Flexion  of  Leg  and  Thigh. — This  deals  with  the  simul- 
taneous flexion  of  the  joints  at  the  hip  and  the  knee.  The 
patient  stands  before  the  apparatus  with  both  feet  on  the 


FIG.  98. 


FIG.  99. 

same  level.  The  foot  to  be  exercised  is  placed  on  the  pedal, 
and  the  patient  should  lean  upon  the  lateral  uprights  and 
raise  the  foot. 


MANIPULATIVE  TREATMENT 


185 


11.  Flexion  and  Extension  of  the  Knee. — This  deals  with 
the  bending  of  the  leg  at  the  knee-joint.  Place  the  patient 
in  the  armchair  and  lower  him  until  the  knee-joint  is  level 
with  the  rotatory  axis  of  the  apparatus. 

Flexion. — The  leg  to  be  exercised  is  placed  on  the  padded 
carrier  of  the  support.  This  cross-bar  must  rest  a  little  above 
the  heel.  The  thigh  is  fastened  with  straps  to  the  seat. 

Extension. — The  leg  to  be  exercised  is  placed  behind  the 
carried  the  cross-bar  resting  above  the  joint  of  the  foot. 


FIG.  100. 


The  little  weight  which  is  placed  oil  the  lever  is  meant  to 
counterbalance  the  weight  of  the  leg  in  the  flexion  move- 
ment. In  order  to  fulfil  this  condition,  it  should  be  fixed 
to  the  end  of  the  lever — letter  F.  In  the  extension  move- 
ment it  should  be  fixed  to  the  letter  E  near  the  axis  of  rota- 
tion. Cases  of  ankylosis  of  the  knee  require  forcible  exten- 
sion or  flexion.  To  obtain  forcible  flexion  the  apparatus 
is  placed  in  the  extension  position.  To  obtain  forcible  ex- 


186        MANUAL  OF  PHYSIO-THERAPEUTICS 

tension  the  apparatus  is  placed  in  the  flexion  position.  Care 
is  then  needed  to  change  the  weights  gradually  and  without 
jarring. 

12.  Cireumduction  of  the  Foot. — Place  the  foot  in  the  iron 
stirrup  and  then  fasten  firmly  with  a  strap,  Cireumduction 
is  carried  out  by  a  series  of  movements  of  flexion  and  ex- 
tension of  the  foot.  The  extent  of  the  movements  can  be 
regulated  at  will  by  flexing  the  rod  at  a  greater  or  lesser 
distance  from  the  axis  of  the  wheel  on  the  iron  sector.  The 
handle  placed  on  the  wheel  allows  of  the  movement  being 
carried  out  passively. 


FIG.  101. 

The  great  advantage  of  these  machines  is  that  the  patient 
can  use  them  for  himself  (active  treatment),  or  it  can  be 
done  for  him  by  a  skilled  operator  (passive  movement). 

The  benefit  derived  is  always  enhanced  by  the  subsequent 
use  of  bathing  and  douching  in  one  form  or  another. 

Good  results  have  been  obtained  from  these  machines 
alone  in  a  very  great  number  of  cases  treated — injuries 
resultant  from  the  war.  Better  and  quicker  results  are 
obtained,  however,  by  combining  soaking  the  part  affected 
in  hot  saline  solution,  following  with  massage  and  passive 
movements,  and  then  finishing  with  the  mechanical  appara- 
tus. The  exercises  are  divided  into  active,  the  patient  doing 


MANIPULATIVE  TREATMENT  187 

the  work  himself ;  and  passive,  the  work  being  done  for  him ; 
also  duplicated,  the  work  partially  done  by  the  patient  assisted 
or  resisted  by  the  operator.  The  Zander  or  Borderel  appara- 
tus lend  themselves  most  admirably  to  the  duplicated  exer- 
cises, which,  on  the  whole,  are  the  most  effectual. 


FIG.  102.— MECHANOTHERAPY  SECTION. 

Zander  exercises,  which  are  carried  out  by  a  system  of 
power-driven  machines,  are  seldom  useful  and  often  danger- 
ous, capable  of  doing  much  harm,  though  sometimes  pro- 
ducing good  results. 

Other  forms  of  exercise  in  \\hich  the  movements  are 
wholly  active  are — (1)  Wall  bars;  (2)  climbing  pegs;  (3)  grip 
dumb-bells;  (4)  the  Velotrab.  or  fixed  cycle;  and  (5)  the 
weight  and  pulley  machine. 

The  Physiology  of  Muscular  Exercise. 

Apart  from  remedial  muscular  exercises,  a  knowledge  of 
the  changes  taking  place  in  the  body  during  muscular 
exertion  is  of  wide  interest  to  everyone.  It  is,  above  all, 
important,  however,  that  the  physician  who  has  to  decide 
daily  what  amount  of  exercise  his  patients  are  fit  for  should 


188        MANUAL  OF  PHYSIO-THERAPEUTICS 

be  familiar  with  the  changes  which  are  produced  by  muscu- 
lar activity  on  the  various  organs  of  the  body;  and,  most 
important,  the  effect  on  the  cardiac  and  respiratory  organs. 
Bainbridge  defines  muscular  exercise  as  the  highest  expres- 
sion of  the  activities  of  the  body  considered  merely  as  a 
machine.  Almost  all  the  resources  of  the  body  are  mobilized 
to  bring  about  the  greatest  efficiency  of  the  neuro-muscular 
system. 

It  is  very  remarkable  to  observe  at  any  time  the  wonder- 
ful co-ordination  of  muscular  movements  and  the  immense 
capacity  of  the  body  to  develop  energy  in  a  professional 
athlete  or  trained  gymnast.  The  highest  pitch  of  training 
is  only  attained  by  constant  practice  and  the  concentration 
for  the  time  being  of  the  nervous  system  and  mentality 
of  the  individual  on  the  actual  muscular  movements  carried 
out.  This  is  one  of  the  most  essential  factors  in  physical 
training.  Nevertheless,  the  actual  energy  for  the  carry- 
ing out  of  physical  work  is  actually  developed  in  the 
muscles  themselves,  and  their  power  to  transform  potential 
into  kinetic  energy  is  the  central  fact  of  muscular 
exercise. 

It  is  quite  clear,  however,  that  the  processes  taking  place 
in  the  muscles  themselves  constitute  only  a  fraction  of  the 
total  activities  of  the  body  during  exercise.  Oxygen  is 
always  necessary  for  the  restoration  of  the  potential  energy 
of  any  muscle;  in  its  absence,  mammalian  muscle  quickly 
loses  its  power  of  contraction.  In  ill-ventilated  mines,  for 
instance,  coal-workers  quickly  become  fatigued  and  their 
output  falls  off.  It  has  further  to  be  borne  in  mind  that, 
since  the  energy  of  muscular  work  is  ultimately  obtained 
from  the  oxidation  of  food-stuffs,  along  with  increased 
muscular  energy,  there  is  a  rise  in  the  intensity  of  their 
metabolic  activity  and  oxygen  consumption.  Briefly,  the 
oxygen  consumption  is  an  index  of  muscular  activity  during 
exercise. 

Brisk  muscular  effort  taxes  the  resources  of  the  cardiac 
and  respiratory  systems  equally  with  those  of  the  muscles 
themselves,  and,  generally  speaking,  the  heart  reaches  its 
limit  of  endurance  sooner  than  the  skeletal  muscles.  We 
know  that  in  running  for  a  train  we  usually  get  winded 


189 

before  our  leg  muscles  fail  materially,  though  that  soon 
follows.  Elderly  people  get  an  early  warning  that  the  limit 
of  their  athletic  capacity  has  been  reached,  and  if  they  are 
wise  they  take  it. 

The  effect  of  physical  training  is  to  bring  about  a  perfect 
co-ordination  between  the  circulatory  and  respiratory 
systems  on  the  one  hand,  and  the  skeletal  muscles  on  the 
other,  so  that  a  maximum  amount  of  work  is  produced  with 
a  minimum  of  effort.  Anything  less  means  inefficiency. 
Competitive  efforts  between  trained  and  untrained  persons 
will  quickly  demonstrate  the  great  importance  of  this  fact. 
It  is,  however,  quite  remarkable  how  people  even  beyond 
middle  life,  not  strangers  to  tobacco  or  alcohol,  will,  after 
a  period  of  abstention  and  graduated  effort,  attain  a  high 
degree  of  efficiency  and  muscular  "fitness." 

In  the  trained  athlete  every  muscle  and  organ  works 
smoothly  with  perfect  harmony  of  action,  while  with  the 
less  trained  person  there  is  greater  sense  of  effort,  clumsiness 
of  movement,  and  notably  more  severe  cardiac  and  respira- 
tory distress. 

In  muscular  exercise,  therefore,  there  are  three  points  to 
bear  in  mind:  (1)  The  changes  in  the  skeletal  muscles  lead- 
ing to  the  output  of  energy;  (2)  the  changes  occurring  in 
other  parts  of  the  body  to  provide  the  muscles  with  oxygen 
and  food-stuffs  for  this  purpose ;  and  (3)  the  means  by  which 
these  are  interwoven  and  correlated  to  produce  the  whole 
fabric  of  muscular  exercise. 

The  Relation  to  Food-Stuffs. — Usually  protein  foods  do  not 
serve  as  a  source  of  energy  during  exercise,  the  energy  being 
mainly  derived  from  hydrocarbons  or  carbohydrates.  When 
both  are  available,  the  skeletal  muscles  display  a  preference 
for  carbohydrates.  The  net  efficiency  of  the  body  machine 
varies  from  20  to  as  high  as  33  per  cent.  (Bainbridge). 

The  factors  influencing  mechanical  efficiency  are  training, 
the  speed  of  the  work  performed,  and  fatigue. 

Oxygen  Consumption. — To  meet  the  demands  of  the  tissues 
for  oxygen  during  exercise,  not  only  is  a  more  rapid  rate  of 
circulation  necessary,  but  there  must  be  a  close  correlation 
between  the  pulmonary  ventilation  and  the  rate  of  the  heart- 
beat. The  circulation-rate  around  the  body  depends 


190        MANUAL  OF  PHYSIO -THERAPEUTICS 

primarily  on  the  output  of  the  heart,  which  varies  from 
3  to  5  litres  per  minute  at  rest  to  20  litres  or  more  during 
heavy  work. 

A  large  output  calls  for  a  corresponding  increase  in  the 
diastolic  filling  of  the  heart.  While  exercise  is  being  carried 
out  the  return  of  blood  to  the  heart  is  increased,  partly  by 
the  active  muscles,  which  mechanically  squeeze  the  blood 
out  of  their  capillaries  and  veins  into  the  greater  veins,  and 
partly  by,  the  respiratory  movements,  especially  those  of 
the  diaphragm. 

The  heart  can  increase  its  output  per  minute  either  by 
larger  output  per  beat  or  by  acceleration  of  the  pulse-rate. 
The  output  of  the  heart  per  beat  depends  on  "the  law  of 
the  heart  "  that  the  force  with  which  the  heart  muscle  con- 
tracts depends  on,  or  varies  directly  with,  the  volume  of  the 
heart  at  the  end  of  diastole. 

Physiological  dilatation  of  the  heart  is  known  to  occur 
during  active  exercise,  with  the  result  that  the  heart  is 
unable  to  increase  its  output  per  beat  in  response  to  a  large 
venous  inflow. 

The  physiological  limit  is  reached  when  the  heart  at  the 
end  of  diastole  fills  the  pericardia!  sac. 

The  influence  of  the  acceleration  of  the  pulse  on  the  out- 
put of  the  heart  per  minute  is  determined  by  the  rate  at 
which  the  heart  fills  during  diastole.  If  the  venous  flow 
is  small,  the  heart  fills  fairly  uniformly,  so  that  little  change 
in  the  output  occurs.  If,  however,  the  venous  inflow  is 
rapid,  the  heart  fills  almost  completely  during  diastole, 
and  the  output  per  minute  increases  almost  proportionately 
with  the  acceleration  of  the  pulse. 

A  fall  of  pressure  in  the  great  veins  occurs  from  blood 
being  transferred  rapidly  from  the  venous  to  the  arterial 
system. 

The  output  of  the  heart  per  minute  depends  on  the  con- 
tractile power  of  its  fibres  and  its  rate  of  beat,  and  the  rate 
of  the  pulse  during  exercise  and  its  acceleration  partly  on 
cortical  impulses  to  the  vagus  and  accelerator  centre,  and 
partly  to  the  influence  of  the  rise  of  temperature  of  the 
body  on  the  vagus  centre,  which  also  is  reduced  in  tone 
from  the  reflex  effect  of  great  diastolic  distension  of  the  heart. 


MANIPULATIVE  TREATMENT  191 

There  is  always  a  close  connection  between  the  frequency 
of  the  pulse  and  the  intensity  of  muscular  work.  It  must 
be  concluded  that  impulses  from  the  cerebral  cortex  to  the 
skeletal  muscles  run  parallel  with  others  to  the  vagus  and 
accelerator  centres. 

The  maximal  pulse-rate  of  about  160  during  exercise  is 
much  the  same  in  different  individuals,  but  the  maximum 
output  of  the  heart  per  minute  varies,  and  depends  on  the 
capacity  of  the  heart  in  different  subjects  to  increase  its  output 
per  beat — in  short,  on  its  contractile  power  and  the  tone  of 
the  muscle  fibres. 

The  mechanical  efficiency  of  the  heart  varies  from  20  to 
30  per  cent.,  and  is  higher  than  that  of  the  body  as  a  whole ; 
it  quickly  diminishes,  however,  if  the  pulse  accelerates  during 
exercise  without  a  proportional  increase  in  the  output  of 
the  heart  per  minute.  The  immediate  effect  of  this  larger 
output  is,  of  course,  to  increase  the  blood-supply  to  the 
active  skeletal  muscles,  the  flow  of  blood  in  which  may  in- 
crease from  six  to  eight  times  what  it  was  during  rest. 

The  blood-pressure  rises  in  the  arteries  during  exercise 
as  a  result  of  the  increased  cardiac  output,  constriction  of 
the  splanchnic  vessels,  and  dilatation  of  the  vessels  of  the 
muscles  and  skin.  Constriction  of  the  splanchnic  vessels 
is  due  mainly  to  central  impulses  to  the  vasomotor  centre. 
It  is  possible  that  the  centre  is  also  stimulated  by  the  greater 
H-ion  concentration  of  the  blood  during  exercise. 

As  regards  oxygen  consumption,  the  active  muscles  during 
severe  exercise  take  up  from  each  fraction  of  blood  flowing 
through  them  twice  as  much  oxygen  as  during  rest ;  and  as 
the  circulation-rate  is  greatly  increased,  the  actual  oxygen 
consumption  is,  of  course,  enormously  enhanced.  Oxygen 
reaches  the  tissues  from  the  blood  mainly  by  diffusion, 
and  once  the  oxygen  reaches  them  it  quickly  enters  into 
chemical  combination,  so  that  the  oxygen  tension  in  the 
tissues  is  nil.  The  rate  of  diffusion  varies  with  the  oxygen 
tension  in  the  blood-plasma,  which  is  again  dependent  on 
the  rate  of  dissociation  of  the  oxyhsemoglobin  in  the 
capillaries.  During  exercise  this  is  much  quickened,  from 
the  increased  H-ion  concentration  of  the  blood. 

Exercise    calls    for    far    more    work    than   is    necessary 


192         MANUAL  OF  PHYSIO-THERAPEUTICS 

when  the  body  is  at  rest,  and  there  is  much  greater 
demand  for  oxygen;  the  ability  of  the  heart  to  meet 
the  calls  on  it  will  depend  largely  on  its  intrinsic  blood- 
supply  ;  the  flow  of  blood  through  the  coronary  arteries  may 
be  as  much  as  six  times  greater  than  it  is  at  rest  (Bain- 
bridge).  Rise  in  blood-pressure  in  the  arteries  and  dilata- 
tion of  the  coronaries  is  essential  to  meet  the  needs  of  the 
human  heart  during  exercise. 

Taking  a  broader  view,  however,  we  have  to  remember 
that  the  activities  of  the  skeletal  muscles,  the  nervous 
system,  the  heart,  and  lungs,  have  to  be  co-ordinated  and 
linked  together,  so  that  the  body  during  exercise  may.  act 
as  a  physiological  unit.  The  activity  of  the  skeletal  muscles 
is  correlated  with  the  rest  of  the  body  in  three  ways : 
(1)  The  greater  mechanical  activity  of  the  muscles  in  return- 
ing blood  more  rapidly  to  the  heart;  (2)  the  increased  H-ion 
concentration  of  the  blood  and  increased  flow  through  the 
muscles;  and  (3)  the  greater  outflow  of  impulses  from  the 
higher  centres  to  the  medullary  centres. 

Under  the  stress  of  excitement  or  competition  a  man  may 
be  able  to  carry  out  much  greater  muscular  efforts  than  he 
is  ordinarily  capable  of,  and  the  fuller  mobilization  of  the 
resources  of  the  body  under  these  conditions  is  only  possible 
if  the  greater  muscular  effort  is  accompanied  by  corre- 
sponding increase  of  the  blood-supply  to  the  muscles,  heart, 
and  brain,  with  efficiency  of  the  circulatory  and  respiratory 
adjustments. 

A  man's  maximum  working  capacity  is  ultimately  deter- 
mined, not  by  the  functional  capacity  of  his  skeletal  muscles, 
but  by  the  supply  of  oxygen  to  muscles,  heart,  and  brain. 
The  limit  of  his  exertions  is  reached  when  the  output  of  the 
heart  fails  to  respond  to  the  demand  of  the  tissues  for  oxygen. 

It  is  axiomatic  that  anything  like  the  maximum  capacity 
or  degree  of  efficiency  can  only  be  obtained  by  training. 
Regular  and  progressive  exercise  is  the  essential  feature  of 
such  training;  the  food  taken,  while  of  moment,  is  entirely 
a  subsidiary  matter.  Proper  training  develops  the  skeletal 
muscles  and  the  heart,  which  in  a  healthy  man  progress  pari 
passu.  As  the  heart  acquires  increased  contractile  power 
its  output  per  beat  is  larger,  so  that  the  pulse-rate  is  usually 


MANIPULATIVE  TREATMENT  193 

slower  in  the  trained  man  even  when  at  rest  than  in  the 
untrained.  With  the  same  amount  of  exercise  in  the 
trained  and  untrained,  this  again  holds  true.  It  is  partly 
due  to  the  greater  output  of  the  trained  heart,  but  also  to 
the  greater  coefficient  of  utilization  and  oxygen-carrying 
power  in  the  trained  man;  less  output  per  minute  is  thus 
called  for.  Training  also  brings  about  a  better  co-ordination 
of  movement  and  improves  the  mechanical  efficiency  of  the 
body,  so  that  work  is  performed  with  the  utmost  economy 
of  effort. 

Trained  men  also  get  what  is  known  in  sporting  circles 
as  their  "second  wind."  In  this  state  the  tension  of  CO., 
in  the  pulmonary  alveoli  falls,  and  there  is  a  decrease  in  the 
pulmonary  ventilation;  there  may  be  at  the  time  a  diminu- 
tion in  the  H-ion  concentration  in  the  blood,  as  a  result  of 
the  greater  mechanical  efficiency  of  the  body,  an  improved 
blood-supply  to  the  body  muscles,  and  the  free  exchange  of 
acid  and  base  radicles  between  the  blood  and  the  tissues. 
These  are  probably  some  of  the  causes  contributory  to 
"  second  wind." 

Fatigue. — Fatigue  after  exertion  is  characterized  by  a 
diminished  capacity  for  the  performance  of  work,  accom- 
panied by  certain  subjective  sensations.  The  sensation  of 
fatigue,  however,  does  not  correspond  necessarily  with  the 
actual  fatigue  of  the  individual  when  this  is  measured  by 
his  capacity  for  work.  Fatigue  may  origin-ate  entirely  in 
the  central  nervous  system,  or  partly  in  the  nervous  system 
and  partly  in  the  muscles.  The  latter  is  comparatively 
rare,  while  ordinary  industrial  fatigue,  which  we  all  more 
or  less  feel  at  the  end  of  the  day,  is  of  the  former  type. 
There  is  nothing  to  show  that  the  products  of  muscular 
activity  bring  it  about;  it  is  rather  due  to  an  expenditure 
of  nervous  energy  which  renders  the  subject  unequal  to 
further  sustained  muscular  or  even  mental  effort. 

Good  Results  of  Exercise. — Regular  exercise  has  a  notable 

effect  on  the  whole  life  of  the  individual.     It  promotes  and 

in  most  people  is  essential  to  the  maintenance  of  good  health 

—if  by  that  we  mean  the  highest  efficiency  of  mind  and 

body. 

The  more  active  blood  and  lymph  flow  favours  complete 

13 


194         MANUAL  OF  PHYSIO-THERAPEUTICS 

combustion  of  metabolic  products  and  the  removal  of  waste 
material,  nutrition  being  thus  promoted.  The  speeding-up 
of  the  metabolic  activity  of  the  body  which  is  the  charac- 
teristic feature  of  exercise  involves  the  more  rapid  utilization 
of  reserve  nutritive  material,  and  probably  also  the  more 
complete  oxidation  of  these  materials  within  the  cells.  Cells 
are  thus  not  clogged  by  substances  awaiting  combustion, 
or  by  waste  products  incapable  of  absorption,  but  awaiting 
removal. 

During  exercise  the  additional  energy  provided  by  the 
more  active  chemistry  of  the  tissues  is  expended  as  work 
or  heat;  but  the  exercise  finished,  the  tissue  metabolism 
remains  active  for  a  time,  leading  to  repair  and  building-up 
of  the  tissues.  This  demonstrates  the  importance  of 
regular  games  and  field  sports  for  the  young,  so  that  the 
whole  body  may  develop  along  with  the  mind,  and  shows 
also  that  the  incessant  activity  of  the  healthy  child  is  as 
necessary  for  its  normal  growth  and  health  as  it  is  sometimes 
trying  to  adults. 

Exercise  has  a  most  important  influence  in  keeping  the 
digestive  and  nervous  systems  healthy.  Sedentary  workers 
are  prone  to  suffer  from  dyspepsia,  and  the  cobbler  often 
combines  it  with  Socialism  and  discontent,  it  is  said. 
Regular  exercise  improves  the  appetite,  promotes  the  now 
of  digestive  juices  and  the  passage  of  food  along  the  digestive 
tract  by  mere  mechanical  action  alone.  But,  furthermore, 
it  has  a  very  valuable  indirect  psychic  effect  on  the  individual 
by  diverting  the  ordinary  activities  of  the  mind;  it  reacts 
beneficially  on  the  mental  attitude  and  physical  well-being; 
this  aspect  of  it  is  very  important  in  later  life. 


CHAPTER  III 
MEDICAL  GYMNASTICS 

MEDICAL  gymnastics  consist  in  the  use  of  systematically 
arranged  exercises,  with  the  object  of  securing  the  restora- 
tion or  preservation  of  healthy  functional  activity. 

If  we  do  not  use  our  muscles  or  organs  they  waste  or 
atrophy,  and  the  continuous  adjustment  of  internal  rela- 
tions to  external  relations  which  constitutes  health  is  inter- 
rupted. Wasting  of  muscular  power  may  be  due  purely  to 
an  idle  life  and  neglect  of  exercise  and  games,  which,  it 
must  be  admitted,  is  unusual  in  this  country,  as  the  natural 
Britisher  is  fond  of  all  games  and  sport,  and  possesses,  as 
he  has  shown  in  the  late  war,  a  very  high-class  average  of 
physical  strength  and  endurance  quite  apart  from  any 
mental  equipment.  There  is  no  truer  axiom  than  Mens 
sana  in  corpore  sano.  Among  the  upper  and  middle  classes, 
indeed,  quite  aside  from  sport,  there  has  been  for  the  last 
twenty  years  quite  a  craze  for  exercises.  We  owe  some- 
thing to  Mr.  Eustace  Miles  for  starting  the  habit  or  craze. 
Eugene  Sandow  exploited  the  movement  for  commercial 
ends;  then  came  Miiller  and  exercisers  of  all  sorts  and 
descriptions,  chiefly  of  the  weight  and  pulley  type.  One  of 
the  best  was  Dowel's,  which  the  author  has  had  and  used 
periodically  for  upwards  of  twenty  years.  But  no  special 
apparatus  is  in  truth  required.  Many  most  excellent 
exercises  can  be  carried  out  on  a  square  of  carpet  without 
any  mechanical  aid. 

As  regards  the  conditions  which  give  rise  to  the  necessity 
for  physical  training  and  treatment,  apart  from  neglect  of 
sport  and  games,  the  occasion  may  be  the  constant  necessity 
for  study  and  indoor  work,  or  illness  or  injury  necessitating 
confinement  to  bed. 

195 


196        MANUAL  OF  PHYSIO-THERAPEUTICS 

Beginning  with  massage  to  get  the  patient  on  his  feet 
literally,  we  can  proceed  with  systematic  exercises  which 
will  confirm  and  increase  the  good  the  massage  has  done. 
It  may  be  feared  that  exercise  systems  have  lent  them- 
selves to  abuse  and  tended  to  a  sort  of  valetudinarianism, 
and  have  actually  done  harm  through  too  heavy  exercises 
being  taken  up  by  people  advanced  in  life,  making  too 
great  a  demand  on  their  cardiac  musculature;  but  how 
quickly  young  adults  develop  and  improve  with  physical 
drill  has  been  proved  to  demonstration  in  tens  of  thousands 
of  cases  when  Kitchener's  army  was  being  made  ready. 

If  we  are  asked  how  the  individual  benefits  by  exercises, 
our  reply  is,  By  increased  tissue  change.  Every  movement 
eats  up  so  much  pabulum,  which  has  to  be  replaced  if  waste 
is  not  to  occur.  Waste  matter  finds  its  way  from  the 
muscle  into  the  veins,  thence  to  the  lungs,  and  there  becomes 
oxidized.  Given  adequate  nutrition  and  a  vigorous  circu- 
lation, repair  will  keep  ahead  of  the  waste  so  caused.  CO2 
is  being  constantly  exhaled  and  oxygen  inhaled,  to  be 
absorbed  in  the  muscles;  and  when  engaged  in  active 
exercise  we  know  by  our  quickened  respirations  and  quicker 
pulse  this  process  is  much  increased.  We  all  know  in  the 
vigorous  exercise  of  boxing  how  soon  we  may  get  winded, 
if  not  in  training,  and  here  the  tissue  regeneration  lags 
behind  for  the  moment,  and  a  pause  must  be  made.  Ample 
oxygen  and  good  sound  blood  to  carry  it  are  necessary ;  if 
we  are  anaemic  or  box  in  a  stuffy  room,  then  the  exhaustion 
occurs  much  sooner.  A  muscle  in  contracting  compresses 
a  vein  in  or  near  itself,  promoting  the  flow  of  blood  to  the 
heart ;  every  repetition  of  the  movements  increases  the  flow 
towards  the  heart,  and  it  is  the  scientific  application  of  this 
fact  to  medical  gymnastics  that  forms  the  basis  of  the 
Schott  and  other  heart  exercises. 

When  a  muscular  contraction  has  occurred,  the  veins 
contain  less  than  their  full  complement  of  blood  and  exercise 
a  degree  of  suction  on  the  capillaries,  the  propelling  effect 
of  the  arterial  contraction  increasing  this,  with  a  resultant 
accelerated  flow.  While  contracting,  the  vessels  are  alter- 
nately shortened  and  lengthened;  when  lengthened,  they  of 
course  hold  more  blood  than  in  the  reverse  condition.  The 


MEDICAL  GYMNASTICS  197 

more  muscles  engaged  in  contraction,  the  greater  the  help 
to  the  circulation — a  regular  and  larger  supply  of  blood  is 
propelled  towards  the  heart  by  what  is  called  the  vis  a 
tergo.  When  this  cannot  be  effected  by  exercise,  as  in 
cases  of  serious  illness,  debility,  and  injury,  we  employ 
what  are  known  as  passive  movements  (vide  infra). 

Movement,  therefore,  ultimately  results  in  the  carrying 
of  increased  supplies  of  oxidized  blood  to  the  part  or  parts 
exercised.  Concomitantly  with  increased  cardiac  activity 
the  lungs  have  to  work  harder,  so  to  speak,  and  allow  of  the 
fullest  inspiration  and  expiration  getting  rid  of  waste 
products  and  renewing  the  oxygen  in  the  blood.  To  secure 
this  the  whole  complicated  system  of  joints,  ribs,  and 
muscles  making  up  the  thoracic  wall  require  exercise,  the 
thoracic  cavity  itself  being  distended  and  contracted  to  the 
highest  degree.  A  chest  that  is  flexible  is  of  the  utmost 
importance;  every  healthy  child  has  this  practically,  and 
every  effort  should  be  made  to  retain  and  develop  it. 
Watching  a  child  who  is  stripped,  one  is  at  once  struck 
with  the  easy  flexible  way  the  thorax  expands  and  contracts, 
either  when  deep  breaths  are  taken  intentionally  or  to 
relieve  the  brief  dyspnoea  occasioned  by  a  short  run.  It  is 
our  object  in  the  giving  of  exercises  to  retain  this  free  play 
as  long  as  possible  on  into  adult  life. 

With  the  back  erect,  neck  kept  straight,  head  erect,  chin 
drawn  in,  and  the  chest  generally  elevated,  inspirations  are 
plainly  deep  in  character,  the  oxidation  of  venous  blood  is 
more  thorough,  and  the  circulation  generally  quickened. 

Having  dealt  with  the  immediate  and  most  necessary 
supply  of  oxygen,  we  now  have  to  consider  the  increased 
demand  for  food  of  one  sort  or  another  occasioned  by  exer- 
cise. If  a  great  deal  of  active  exercise  is  taken,  a  diet  in 
which  the  starchy  element  is  cut  clown  and  the  nitrogenous 
increased  will  be  found  best.  Beef,  mutton,  eggs,  with  a 
few  green  vegetables  and  dry  toast,  form  the  staple  portion 
of  the  training  diet  of  a  Cambridge  or  Oxford  undergraduate. 
Beef  and  beer  play  an  equally  important  part  in  the  pabulum 
of  a  ha rd- working  navvy  or  iron-founder. 

If  an  athlete  is  put  through  heavy  exercises  and  underfed, 
he  will  get  stale,  just  as,  if  the  training  is  overdone  with 


198         MANUAL  OF  PHYSIO-THERAPEUTICS 

sufficient  food,  the  same  condition  will  arise.  He  loses  his 
ambition  and  his  vitality  generally  declines ;  he  sleeps  badly, 
wakes  tired,  and  loses  interest  in  his  surroundings.  His 
blood-pressure  falls,  and  the  pulse-rate,  which  should  not 
increase  more  than  eight  in  changing  from  the  sitting  to  the 
standing  position,  increases  by  as  much  as  twenty  or  more. 

Gradual  decline  in  weight  occurs,  and  only  rest — perhaps 
complete  rest,  with  only  massage  and  passive  exercise — 
can  restore  him. 

It  cannot  be  absolutely  laid  down  that  animal  diet  is 
essential  to  fitness,  but  it  appears  to  be  largely  so  with 
Western  European  races.  On  the  other  hand,  both  Chinese 
and  Japanese  thrive  on  a  purely  rice  and  vegetable  diet, 
and  the  latter  more  particularly  engage  in  sports  of  the 
most  arduous  kind,  and  are  adepts  at  the  art  of  war  and 
highly  virile,  as  they  fully  demonstrated  in  their  war  with 
Russia  in  1904  and  1905. 

A  good  development  of  the  abdominal  muscles  usually 
goes  with  a  good  digestion,  and  exercises  tending  to 
strengthen  these  usually  go  to  promote  good  health,  ample 
secretion  of  digestive  juices,  and  the  condition  generally 
called  "  eupepsia."  The  abdominal  organs,  almost  without 
exception,  can  be  powerfully  influenced  either  by  exercise 
or  manipulations  and  vibration. 

Vibration  over  the  liver,  it  may  be  said,  will  do  as  much 
in  five  minutes  to  promote  the  flow  of  bile  as  forty  minutes 
on  horseback,  and  a  few  minutes'  gentle  scratching  on  the 
skin  just  below  the  left  costal  margin  will  quickly  open  the 
pylorus  and  cause  emptying  of  the  stomach  towards  the 
later  stages  of  digestion.  Kidney  and  liver  activity  are  also 
promoted  by  trunk  flexions  and  rollings.  General  ab- 
dominal massage  and  the  use  of  flexions  of  the  trunk  and 
of  the  limbs  on  the  trunk  powerfully  combat  constipation. 

The  general  effect  of  gymnastics  and  athletic  training  is 
to  put  the  various  body  systems  in  a  condition  of  equi- 
poise, minimizing  the  fluctuation  from  the  normal  in  every 
case.  The  comparatively  slight  increase  in  pulse  and 
respiration  rate  of  an  athlete  in  training  after  a  four-mile 
scamper  is  surprising  to  the  city  man,  who  gets  puffed 
running  fifty  yards  to  catch  his  train  to  the  suburbs. 


MEDICAL  GYMNASTICS  199 

Further,  broadly  speaking,  men  who  are  athletically 
trained  and  accustomed  to  hard  out-of-door  work  seldom 
get  troubled  with  nerves,  though  we  must  confess  that  on 
a  deviation  from  the  normal  a  very  healthy  man  sometimes 
does  show  an  overadequate  display  of  concern  !  It  is  not 
suggested  that  mental  training  can  be  disregarded,  but 
those  men  who  become  useful  citizens,  Members  of  Par- 
liament or  party  leaders,  have  often  rowed  in  their  college 
eight  and  neglected  no  form  of  sport,  and  compare  favour- 
ably, when  all  is  said  and  done,  with  the  dyspeptic  Carlyle, 
who  was  declared  by  his  own  mother  to  be  "  ill  to  live  with," 
or  the  vitriolic  Voltaire. 

Exclusive  devotion  to  physical  training  merely  produces 
brute  force,  sometimes  associated  with  lack  of  control  and 
initiative,  but  really  scientifically  directed  gymnastics 
tend  to  preserve  health  through  the  whole  period  of  man- 
hood, combating  abnormal  developments,  and  fitting  the 
whole  organism  to  carry  on  the  functions  of  life  to  the  best 
advantage. 

There  is  a  certain  moral  tonic  even  in  what  is  termed 
"a  good  carriage  "  to  the  person  himself,  and  it  helps  to 
constitute  what  we  know  as  "presence" — a  very  helpful 
possession  in  the  struggle  of  life. 


200         MANUAL  OF  PHYSIO  THERAPEUTICS 


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MEDICAL  GYMNASTICS  201 

The  Bruce-Sutherland  System. 


FIG.  103,  No.  1. — CHEST  EXERCISE — INHALING  DEEPLY,   HANDS 
AT  CHEST,  EXTEND  ARMS. 

Position. — Stand  erect  witli  liead  well  thrown  back,  feet  together, 
and  elbows  raised  in  a  line  with  the  chest.  The  arms  being  bent, 
the  hands  will  be  in  front  of  the  chest,  palms  downwards,  and  thumbs 
touching  the  body. 

Action. — The  upper  trunk  muscles  are  used.  While  inhaling 
deeply,  open  out  the  arms  firmly,  describing  a  half-circle  with  the 
hands  until  they  are  in  a  perfect  line  with  the  shoulders  and  as  far 
apart  as  possible;  that  is  to  say,  you  must  stretch  the  shoulders 
outwards.  At  the  same  time,  throw  the  weight  of  the  body  forward, 
rising  on  the  toes,  the  lungs  being  thoroughly  inflated.  In  that 
position  pause  slightly,  then  relax,  falling  back  on  the  heels;  exhale 
naturally  without  forcing,  and  bring  the  hands  back  to  the  chest  again. 

This  extremely  beneficial  exercise  should  be  repeated  ten  times 
for  a  beginning,  and  should  always  be  performed  with  a  free  swinging- 
motion,  never  in  a  jerky  manner. 


202         MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.    104,   No.    2. — UPPER    TRUNK    AND    LUNG    EXERCISE  — 
STEPPING  OUT,  ARMS  RAISED  ABOVE  HEAD. 

Position. — This  exercise  is  designed  to  strengthen  the  chest  and 
back.  Stand  erect  with  the  arms  down  in  front  of  the  body,  lianas 
touching  the  legs.  Keep  the  head  well  back,  lips  closed,  feet  together, 
shoulders  braced  well  backwards. 

Action. — With  the  right  foot  step  outwards  on  the  toes  only, 
keeping  the  heels  well  off  the  ground,  and  at  the  same  time  raise 
the  hands  high  above  the  head,  making  the  muscles  rigid,  so  that 
they  may  act  as  a  lever  upon  the  chest.  Inhale  deeply  through  the 
nostrils,  and,  looking  slightly  upwards  and  bending  the  back,  make 
a  momentary  pause.  Then  go  back  to  the  starting  position,  at  the 
same  time  exhaling  and  bringing  the  arms  firmly  down  again  to  the 
front.  This  exercise  may  be  performed  for  a  beginning  ten  times, 
stepping  out  with  each  foot  alternately. 

NOTE. — Keep  the  heels  well  off  the  ground,  as  much  spring  is 
thus  gained  and  the  spinal  column  will  be  brought  into  play  to  a 
greater  extent  when  stepping  out. 


MEDICAL  GYMNASTICS 


203 


FIG.  105,  Xo.  3. — SIDE,  SHOULDER,  AND  BACK  EXERCISE — SIDE 
SWAYING,  ARM  RAISED  OVER  HEAD. 

This  exercise  is  designed  for  improving  the  carriage  and  strengthen- 
ing the  spine. 

Position.— Open  out  the  feet,  hands  resting  on  the  waist  and 
body  well  thrown  back. 

Action. — Inhale  deeply,  raising  the  right  arm  outward  and  upward 
until  the  hand  is  stretched  over  the  head.  At  the  same  time  bend 
the  body  (side  bending)  over  to  the  left,  taking  care  not  to  incline 
the  frame  forward,  as  this  would  cause  a  relaxation  of  the  pressure 
on  the  back  muscles.  Having  brought  the  right  arm  over  the  head 
to  the  left  as  far  as  possible,  make  a  momentary  pause,  exhaling, 
then  bring  the  arm  down  again,  hand  to  the  waist,  raising  the  body 
to  the  starting  position.  The  moderate  swaying  motion  has  a  most 
beneficial  effect  on  the  internal  organs,  particularly  helpful  to 
constipated  subjects. 

This  exercise  is  sometimes  performed  with  the  feet  together,  but 
the  sideways  movement  is  then  to  some  extent  restricted.  Repeat 
ten  times,  raising  the  right  and  the  left  arm  alternately. 


204         MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.     106,    Xo.    4.  —  STKIKIXG-OUT    MOVEMENT  —  EXERCISE    FOR 
SHOULDERS,  BACK,  AND  CHEST,  TOGETHER  WITH  LEG  AND  ARM 

MUSCLES. 

Position. — Bring  both  hands  to  chest,  with  elbows  close  to  sides, 
feet  together,  and  shoulders  back. 

Action. — Step  out  with  the  left  foot  and  strike  out  with  the  right 
arm,  forcing  it  straight  out  in  front  with  hand  closed  and  muscles 
of  the  arm  tense.  Do  not  lower  the  hand  as  the  body  goes  slightly 
downwards  on  forward  motion.  The  front  leg  should  be  bent,  with 
the  heel  raised  slightly  off  the  ground,  the  rear  leg  perfectly  straight. 
Having  struck  out  to  the  fullest  extent,  draw  the  hand  firmly  back 
to  the  chest  again,  at  the  same  time  stepping  back  to  the  starting 
position,  relying  on  the  ball  of  the  foot  for  the  spring  back.  Repeat 
this  movement  with  the  right  leg  and  left  arm.  Repeat  it  ten 
times  in  all,  starting  with  the  left  and  right  foot  alternately. 

NOTE. — It  is  naturally  easier  to  strike  out  with  foot  and  hand 
corresponding — left  foot  and  left  hand  or  right  foot  and  right  hand 
— but  the  beneficial  effect  is  not  so  great. 


MEDICAL  GYMNASTICS 


205 


Fie    107,  Xo.  5. —WINDMILL  MOVEMENT. 

This,  exercise  brings  into  play  practically  every  muscle  in  the 
body,  and  develops  the  chest  and  lungs. 

Position. — Left  hand  at  waist,  the  other  at  the  side,  frame  erect, 
and  head  thrown  back. 

Action. — Bend  down  until  the  right  hand  touches  the  ground; 
then  raise  the  hand  in  circular  movement  above  the  head,  rising  on 
toes  and  inhaling;  then  bring  the  arm  down  vigorously  to  the  rear. 
Keep  the  arm  straight,  the  hand  closed,  and  the  muscles  firm. 
Inhale  on  the  upward  movement,  and  exhale  on  the  downward. 
Follow  the  movement  with  the  eyes;  thus,  as  you  bring  down  the 
arm  to  the  rear  you  will  turn  the  head  in  that  direction.  The  arm 
not  in  use  will  remain  at  the  waist,  elbow  to  the  rear,  and  should 
on  no  account  hang  limply  at  the  side.  \Vhen  beginning  the  exercise, 
if  you  are  not  quite  able  to  reach  the  ground,  go  down  as  far  as  you 
can  comfortably  do  so,  but  on  no  account  stretch  the  muscles  un- 
duly. Repeat  ten  times  with  each  arm  alternately. 


206         .MANUAL  OF  PHYSIO-THERAPEUTICS 


Fir;.  108,  No.  0. — DEEP-BREATHING  AND  CHEST-EXPANDING 
EXERCISE— -ARMS  EXTENDED  IN  FRONT. 

This  is  ;i  simple  yet  valuable  exercise  for  the  muscles  of  Ihe  chest. 

Position.  -Stretch  the  arms  out  firmly  in  Ironl  <>t  the  body  in  a 
line  with  the  shoulders,  hands  touching,  fingers  closed,  shoulders 
kept  well  back. 

Action. — Open  the  arms  well  out  until  they  are  parallel  with  the 
shoulders,  at  the  same  time  inclining  the  body  forward  in  order  that 
the  chest  may  have  greater  expansion,  and  rising  slightly  off  the 
heels.  Breathe  in  deeply,  with  the  chin  raised;  make  a  momentary 
pause,  keeping  the  lungs  inflated;  then  slowly  bring  the  arms  to 
the  front  again  without  lowering  until  the  hands  meet,  breathing 
naturally  and  falling  back  on  the  heels.  The  muscles  of  the  arm 
should  remain  tense  while  this  exercise  is  being  performed,  and  the 
movement  should  not  be  performed  too  quickly. 


207 


FIG.  109,  Xo.  7. — EXERCISE  FOR  THE  FOOT  AXD  LEG  MUSCLES. 

This  exercise  is  designed  for  the  strengthening  of  the  spring  of 
the  foot  and  improving  the  calf  muscles,  thus  developing  the  walking- 
powers. 

Position. — Stand  erect,  hands  at  waist,  feet  together. 

Action. — Rise  high  on  the  toes,  raising  the  hands  to  the  chest  in 
order  to  put  tension  upon  the  muscles  of  the  body;  throw  the 
shoulders  well  back  while  yet  remaining  upright,  in  order  to  preserve 
the  balance;  the  muscles  must  be  tense.  The  forearm  and  wrist 
muscles  may  also  be  exercised  in  this  movement  by  closing  the 
hands  tightly  on  the  upward  movement,  and  opening  them  out, 
each  finger  apart,  on  the  downward.  This  leg  exercise  will  be  found 
invaluable  for  remedying  any  weakness  in  the  instep.  Repeat 
twenty  times  for  a  beginning. 


208        MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  110,  Xo.  8. — LEG-RAISING  MOVEMENT. 

This  leg-raising  movement  is  one  of  the  most  powerful  exercises 
known  for  building  up  the  lower  trunk. 

Position. — Stand  erect,  with  the  hands  at  the  waist. 

Action. — Bend  the  body  forward,  at  the  same  time  raising  one 
leg  upward  as  far  as  possible;  then  bring  the  body  firmly  backward, 
at  the  same  time  bringing  the  leg  smartly  downward.  Notice  the 
action  here  is  twofold — the  raising  of  the  lower  limb  to  the  fullest 
extent  and  the  bending  forwards  of  the  upper  portion  of  the  frame. 
This  has  the  effect  of  preserving  the  balance,  and  at  the  same  time 
contracting  the  abdominal  parts  and  extending  the  spinal  region 
of  the  frame;  a.  curve  forward  is  formed  when  the  body  is  thrown 
forward  and  the  limb  upward,  and  a  curve  in  the  opposite  direction 
when  the  leg  is  lowered  and  the  body  thrown  backwards.  The 
average  person  should  with  practice  so  improve  his  joint  action  that 
he  will  eventually  kick  his  own  height.  Repeat  this  ten  times, 
using  each  leg  alternately. 


MEDICAL  GYMNASTICS 


209 


FIG.  Ill,  No.  9. — SIDE-BENDING  EXERCISE — ARMS  SWINGING 
ABOVE  HEAD. 

This  powerful  side-bending  movement  brings  into  play  and 
exercises  every  part  of  the  body. 

Position. — Stand  erect,  with  the  arms  extended  in  line  with  the 
shoulders,  and  feet  well  apart,  chest  out,  and  lungs  inflated. 

Action. — Bend  over  the  body  to  the  left,  the  right  hand  describing 
a  circle  over  the  head  and  going  down  to  the  left  foot  by  much  the 
same  action  as  would  be  required  in  bowling  at  cricket.  Take  care 
that  the  arms  are  kept  in  a  direct  line  with  the  shoulders,  so  that 
when  the  right  arm  goes  down  to  the  left  foot  the  left  arm  will 
point  upwards,  having  completed  half  a  circle  up  the  back,  which, 
of  course,  it  is  bound  to  do  if  the  arms  are  kept  parallel  with  the 
shoulders  all  the  time.  As  you  rise  up  again  do  not  cut  corners 
by  raising  the  hand  from  the  foot  to  the  starting  position,  but  bring 
the  right  hand  up  the  left  side,  then  over  the  head  to  the  starting 
position  again.  Repeat  with  the  left  arm  to  the  right  side.  Repeat 
ten  times  for  a  beginning,  inhaling  on  the  upward  and  exhaling  on 
the  downward  movement. 

14 


210         MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  112,  Xo.   10. — CHEST,  BACK,  AND  TRICEPS  EXERCISE — 
STEPPING  OUT,  THROWING  ARMS  TO  REAR. 

Position. — Stand  erect  with  the  shoulders  back,  elbows  close  to 
the  sides,  and  hands  at  the  chest,  palms  turned  outwards. 

Action. — Step  out  briskly  with  the  right  foot,  and  at  the  same 
time  throw  the  body  forward,  but  keep  the  back  perfectly  straight 
and  the  head  thrown  back,  so  that  the  chest  may  be  opened  out 
and  the  breathing  may  not  be  restricted.  At  the  same  time, 
straighten  the  arms  downwards  smartly  and  swing  them  backwards, 
hands  clenched  and  knuckles  outward,  keeping  the  arms  well  to  the 
sides.  Put  full  pressure  on  the  muscles  of  the  arms,  especially  the 
triceps  muscles  at  the  back  of  the  upper  arm.  When  stepping  out, 
keep  the  whole  weight  of  the  body  on  the  toes.  As  you  spring  back 
into  an  upright  position  bring  the  hands  back  to  the  chest,  keeping 
an  equal  tension  on  the  forward  movement  and  on  the  return.  If 
not  in  good  physical  condition  at  the  beginning,  do  not  bend  forward 
too  far.  Repeat  this  exercise  ten  times,  stepping  out  with  the  right 
and  left  foot  alternately. 


MEDICAL  GYMNASTICS 


211 


FIG.  113,  No.   11. — SIDE-BENDING  EXERCISE- 
AND  ARMPIT. 


-HANDS  TO  KNEE 


This  exercise  is  specially  designed  for  strengthening  the  spine, 
making  the  frame  lithe,  and  building  up  the  waist-line.  It  also 
brings  into  play  the  shoulder  muscles  and  the  side  and  groin  muscles, 
tending  to  reduce  superfluous  flesh. 

Position. — Body  erect,  feet  well  apart,  arms  at  the  sides,  hands 
turned  in  and  close  in  to  legs,  head  erect,  leaning  back  a  little. 

Action. — Bring  the  right  hand  up  along  the  side,  rubbing  the 
surface  of  the  body  closely  on  the  way  up,  until  it  rests  curled  under 
the  right  armpit.  At  the  same  time  the  body  is  raised  on  the  right 
side  and  bent  over  to  the  left.  As  the  right  hand  is  drawn  upward, 
the  left  hand  should  glide  downward  until  it  touches  the  knee  on 
the  outside.  Then  reverse  the  movement  until  the  right  hand  goes 
down  to  the  right  knee,  the  left  hand  going  up  to  the  left  armpit. 
On  no  account  should  the  body  be  allowed  to  bend  forwards.  This 
exercise  causes  a  swaying  to-and-fro  motion.  Repeat  ten  times. 


212        MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  114,  Xo.  12. — CHEST,  SHOULDER,  BACK,  AND  ARM  EXERCISE 

— ARMS    RAISED    ALTERNATELY    ABOVE    HEAD. 

Position. — Hands  clenched  at  the  chest,  head  thrown  back,  body 
inclined  backward,  elbows  to  sides,  and  feet  apart  to  give  a  better 
swing  to  the  body. 

Action. — Stretch  each  arm  alternately  high  above  the  head,  the 
chin  being  raised  and  the  gaze  also  directed  upwards.  When  the 
one  hand  is  extended  as  high  as  possible,  the  other  should  be 
stationary  at  the  chest.  A  steady  pressxire  should  be  applied  upon 
the  muscles,  and  the  movement  performed  without  any  jerky  action 
such  as  might  easily  slip  into  this  exercise.  On  the  downward 
movement  of  the  arms  the  biceps  should  be  kept  tense  and  firm, 
and  the  elbow  should  be  pressed  close  to  the  side.  Breathe  regularly, 
as  the  chest  remains  mobile  during  the  exercise.  This  exercise  is 
frequently  given  with  the  heels  together,  but  if  the  feet  are  opened 
;v  better  swing  is  obtained  on  the  spinal  muscles.  Repeat  the 
movement  ten  times. 


MEDICAL  GYMNASTICS 


213 


FIG.  115,  No.  13. — BODY-BENDING  EXERCISE. 

This  exercise  is  designed  for  strengthening  and  bringing  into 
healthy  condition  the  abdominal  parts.  The  movement  is  excellent 
for  loosening  the  spinal  muscles  and  joints. 

Position. — Bend  the  frame  well  back  with  the  arms  extended 
above  the  head,  hands  open,  palms  to  the  front,  and  thumbs  touch- 
ing. The  eyes  should  be  turned  in  the  direction  of  the  hands,  the 
chin  raised,  and  the  feet  firmly  placed  on  the  ground  slightly  apart. 

Action. — A  good  inhalation  having  been  taken  with  the  chest 
thrown  well  out,  bend  the  body  slowly  forward,  keeping  it  in  line 
with  the  arms  as  much  as  possible,  until  the  fingers  touch  the  toes. 
Provided  the  joints  are  loose  enough,  the  palms  may  even  be  placed 
on  the  floor.  As  there  is  compression  on  the  abdomen  and  chest, 
it  is  advisable  to  expel  all  the  air  from  the  lungs  during  the  down- 
ward motion.  As  the  body  is  being  raised  up  to  the  starting  position, 
inhale  deeply,  keeping  the  chin  clear  of  the  chest,  in  order  that 
there  may  be  perfect  freedom  in,  breathing.  This  exercise  should 
be  performed  very  gradually,  but  as  the  frame  becomes  more  supple 
it  can  be  performed  more  vigorously.  Ten  times  is  sufficient  for 
a  beginning. 


214         MANUAL  OF  PHYSIO-THEEAPEUTICS 


FIG.  116,  No.  14. — REAR-KICKIXG  MOVEMENT. 

This  exercise  is  exceedingly  valuable  for  loosening  the  leg  muscles 
and  giving  the  hip  and  leg  joints,  as  well  as  those  of  the  lumbar 
region,  greater  freedom  of  movement  and  increased  elasticity.  It 
will,  moreover,  prove  beneficial  to  runners  and  others  who  have  a 
tendency  to  cramp  or  stiffness  in  the  legs. 

Position. — -Stand  erect  with  hand  at  the  waist,  elbows  to  the  rear, 
and  tighten  all  the  muscles  from  the  hips  downwards. 

Action. — Bend  the  right  knee,  raising  the  foot  upwards  and 
keeping  it  close  under  the  body.  Bend  the  body  forward;  at  the 
same  time  shoot  out  the  foot  to  the  rear,  as  indicated  by  the  arrow 
in  Fig.  116,  until  the  leg  is  perfectly  straight.  This  must  be  per- 
formed in  one  continuous  movement,  otherwise  you  will  find  it 
extremely  difficult  to  keep  your  balance.  Now  bring  the  foot  down 
to  the  ground  again  and  repeat  with  the  other  limb.  Eepeat  ten 
times  for  a  beginning.  This  exercise  should  be  performed  vigorously, 
but  not  too  quickly. 


MEDICAL  GYMNASTICS 


215 


FIG.  117,  No.  15. — TRUNK-SWINGING  MOVEMENT — TURNING  TO 

EEAR. 

As  a  gentle  movement,  tending  to  improve  the  support  afforded 
to  internal  organs,  this  is  one  of  the  very  best  exercises. 

Position. — Stand  erect,  feet  well  apart,  arms  slightly  bent,  with 
the  arm  muscles  made  rigid,  so  that  the  arms  may  act  as  a  lever 
pulling  around  the  body. 

Action. — Swing  the  body  down  to  the  left,  bring  the  right  arm 
across  to  the  left,  twisting  the  trunk  round  in  the  same  direction  as 
far  as  possible,  and  looking  to  the  rear.  You  will  find  it  very  difficult 
to  perform  this  exercise  to  your  .- atisf action.  The  body  is  rarely, 
if  ever,  required  to  swing  into  this  peculiar  position,  and  therefore 
it  is  difficult  to  carry  it  out  gracefully  at  first,  but  with  a  little 
practice  great  improvement  will  be  noticed.  After  the  body  has 
been  pressed  down,  make  a  slight  pause,  and  then  rise  straight  up 
again,  inhaling.  Repeat,  going  down  again  in  the  opposite  direction. 
Repeat  ten  times,  bending  to  the  right  and  the  left  alternately. 


216        MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  118,  No.  16. — FORWARD-BENDING  EXERCISE — HANDS  BEHIND 

BACK. 

This  exercise  has  a  fine  bracing  effect  on  the  whole  body  frame- 
work, strengthening  the  spinal  column  and  improving  the  carriage 
generally. 

Position. — Stand  erect,  arms  straight  out  behind,  with  hands 
clasped,  palms  outward,  feet  somewhat  apart,  firmly  placed  upon 
the  ground,  and  head  thrown  well  back. 

Action. — After  the  lungs  have  been  filled  and  shoulders  thrown 
back,  bend  the  body  firmly  forward,  keeping  the  spine  straight  and 
the  arms  rigid.  Exhale  while  going  down.  Do  not  bend  the  legs 
as  the  weight  of  the  body  goes  forward,  and  be  sure  that  your  arms 
are  raised  as  far  up  the  back  as  possible  until  they  assume  a  per- 
pendicular position.  Raise  the  frame  up  again,  inhaling  slowly  as 
you  rise,  and,  drawing  the  head  well  back,  throw  out  the  chest; 
make  a  pause,  then  go  down  again,  repeating  the  movements. 
Repeat  ten  times. 


MEDICAL  GYMNASTICS 


217 


FIG.  119,  Xo.   17. — KNEE-BENDING  EXERCISE. 

This  exercise  is  most  effective  in  making  the  joints  of  the  lower 
extremity  loose  and  free,  and  imparts  a  fine  springing  step. 

Position. — Stand  with  the  body  inclining  forward  slightly,  back 
straight,  without  the  slightest  indication  of  stooping,  but  rather 
the  reverse,  with  chest  thrown  out  and  hands  at  waist.  For  those 
advanced  in  years  or  whose  lower  limbs  are  weak  and  muscles  inclined 
to  be  stiff,  it  is  advisable  to  keep  the  arms  outstretched  in  line  with 
the  shoulders  in  order  to  preserve  the  balance  and  prevent  toppling 
over.  Such  persons  should  not  attempt  to  go  too  far  down. 

Action. — Rise  on  the  toes,  then  sink  gently  down  to  the  heels, 
keeping  the  knees  well  apart  and  maintaining  pressure  on  the  leg 
muscles,  sustained  until  the  knees  can  bend  no  further.  Rise  again 
slowly,  remaining  poised  on  the  toes  throughout  the  performance 
of  the  exercise.  This  movement  is  of  great  value  for  those  who 
require  to  use  their  lower  extremities  at  all  strenuously,  and  with 
athletes  shows  surprising  results.  Repeat  slowly  and  steadily  ten 
times. 


218        MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  120,  Xo.  18. — SIDE-BENDING  EXERCISE — ARMS  OUTSTRETCHED. 

This  exercise  tends  to  reduce  tlie  body  circumference  at  the  waist- 
line in  subjects  who  tend  to  accumulate  superfluous  fat  over  the 
abdomen.  It  strengthens  the  muscles  of  the  groin  and  back  and 
the  lateral  muscular  wall  of  the  abdomen. 

Position. — Stand  erect,  arms  tensely  extended  in  a  line  with  the 
shoulders,  and  feet  apart. 

Action. — -Keeping  the  legs  perfectly  steady,  bend  down  to  the 
side  and  touch  the  floor  with  the  left  hand,  the  right  arm  being 
extended  upwards  and  backwards  in  a  line  parallel  with  the  left, 
so  as  to  keep  a  steady  and  equal  pressure  on  both  sides  of  the 
shoulders.  The  proper  time  to  exhale  is  when  the  body  is  down. 
Then  rise  to  an  upright  position,  taking  care  that  both  the  down- 
ward and  upward  motion  shall  be  a  side-bending  and  not  a  front- 
bending  movement.  Perform  the  exercise  ten  times,  bearing  in 
mind  that  if  your  joints  are  not  so  flexible  as  that  of  the  gymnast 
in  Fig.  120,  you  will  probably  attain  an  equal  degree  of  expertness 
with  time  and  perseverance. 


MEDICAL  GYMNASTICS 


219 


FIG    121,  Xo.   19. — XECK  EXERCISE. 

This  movement  will  develop  the  muscles  of  the  neck,  filling  the 
hollows  of  the  throat  and  giving  the  whole  a  splendid  contour. 

Position. — Stand  firmly  in  an  attitude  of  looking  upwards,  with 
the  head  thrown  well  back  and  the  feet  placed  well  apart. 

Action. — -Bring  the  chin  slowly  forward  until  it  rests  firmly  on 
the  chest.  Then,  keeping  the  chin,  down,  turn  the  head  well  round 
into  the  attitude  of  looking  over  the  shoulder,  still  having  the  side 
of  the  head  well  forward.  Then  allow  the  chin  to  sink  down  again 
and  turn  the  head  in  the  opposite  direction.  Great  care  should  be 
taken  to  follow  the  instructions  thoroughly,  so  that  the  utmost 
benefit  may  be  derived.  It  is  not  sufficient  merely  to  swing  the 
head  round  and  look  over  the  shoulder  at  each  turn.  You  must 
not  forget  to  keep  your  head  well  forward  at  the  same  time.  The 
breathing  should  be  regular,  but  not  too  deep,  during  these  some- 
what restricted  movements.  Kepeat  twenty  times,  turning  to  the 
right  and  the  left  alternately. 


220         MANUAL  OF  PHYSIO-THERAPEUTICS 


FlG.   122,  XO.  20.— SIDE-SWINGING  EXERCISE — HANDS  BEHIND 

BACK. 

This  excellent  exercise  develops  a  strong,  lithe  figure,  and  is 
specially  effective  in  strengthening  the  spinal  column  in  the  lumbar 
region.  It  also  tends  to  brace  up  the  internal  organs. 

Position.—  Chest  out,  shoulders  back,  and  head  thrown  backwards. 
Clasp  hands  behind  the  back,  palms  outwards  and  feet  opened  out. 

Action. — -Throw  the  weight  backwards,  and  from  that  position 
bend  the  body  completely  over  to  the  right  side,  taking  care  that 
in  so  doing  the  weight  of  the  body  is  not  thrown  forward.  Endeavour 
as  far  as  possible  to  bring  the  shoulder  close  to  the  leg,  exhaling  as 
you  go  down;  then  pause  for  a  moment  and  rise  up  again,  inhaling. 
Keep  the  arms  perfectly  rigid  during  these  movements.  Eepeat 
the  movement,  bending  now  to  the  left  side.  The  frame  should 
swing  from  side  to  side  in  a  semicircle,  and  the  exercise  be  performed 
in  a  steady  manner  and  not  too  quickly.  Eepeat  ten  times  for  a 
beginning.  Keep  the  head  well  thrown  back  all  the  time. 


MEDICAL  GYMNASTICS 


221 


FIG.  123,  Xo.  21. — CHEST  EXERCISE — HANDS  AT  CHEST,  STRETCHED 
UPWARDS  AND  TO  THE  REAR, 

This  is  one  of  the  very  finest  exercises  that  can  be  carried  out 
with  a  view  to  tuning  up  the  body  to  perfect  condition. 

Position. — -Bring  both  closed  hands  together  in  front  of  chest, 
elbows  close  to  the  body,  arm  muscles  made  firm. 

Action. — Bend  slightly  forward,  so  that  the  body  may  receive 
an  impetus  in  being  stretched  out  as  the  arms  are  thrown  upwards, 
inhaling  deeply  and  rising  on  the  toes  in  order  to  stretch  the  frame 
to  its  fullest  extent.  Then  swing  arms  to  the  rear  in  a  circular 
motion,  keeping  them  outstretched  and  applying  full  pressure  upon 
the  shoulders,  and  bring  the  arms  down,  keeping  them  to  the  rear 
as  far  as  possible.  Fall  back  on  the  heels  as  the  arms  are  brought 
behind,  at  the  same  time  exhaling.  Continue  the  circle  forward  and 
upward  until  the  starting  position  is  regained.  The  knees  must  be 
kept  straight  and  the  chin  raised  on  the  upward  movement.  Repeat 
ten  times,  with  a  slight  pause  after  each  movement. 


222          MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  124,  No.  22. — SIDE-BENDING  EXERCISE — HANDS  AT  WAIST. 

This  exercise  is  the  easiest  of  all  side-bending  movements,  and 
is  therefore  very  suitable  for  anyone  whose  physical  condition  does 
not  warrant  anything  but  the  most  gentle  movements  at  first.  A 
very  stout  person,  for  instance,  may  practise  this  with  entire  safety. 

Position. — Body  thrown  back,  feet  apart,  hands  at  waist,  and 
elbows  back. 

Action. — Having  the  body  equally  balanced  on  both  legs,  bend 
over  to  the  left  side  as  far  as  possible.  Keep  the  body  from  inclining 
forward  as  you  go  over,  otherwise  you  would  be  transferring  the 
work  to  muscles  not  intended  to  be  exercised  in  this  particular 
movement.  Exhale  as  you  bend  the  body  down  sideways,  and 
breathe  in  deeply  on  rising.  The  upper  portion  of  the  frame  should 
be  kept  quite  rigid  throughout  the  execution  of  the  exercise.  Kepeat 
ten  times,  bending  to  the  left  and  right  alternately,  with  a  short 
pause  after  each  complete  movement. 


MEDICAL  GYMNASTICS 


223 


FIG.  125,  No.  23. — FRONT-BENDING  EXERCISE — STEPPING 
FORWARD,  ARM  OUT. 

This  exercise  has  a  bracing  effect  on  the  spinal  column  and  the 
abdominal  muscles.  It  also  loosens  and  develops  the  shoulder 
muscles  and  improves  the  joint  action. 

Position. — Hands  to  sides,  body  thrown  somewhat  backwards, 
and  feet  together. 

Action. — Step  out  with  the  left  foot,  throwing  the  weight  on  the 
toes,  and  as  you  do  so  raise  the  right  arm  smartly  from  the  rear 
and  throw  vigorously  forward  in  much  the  same  manner  as  in 
bowling  at  cricket,  only  the  arm  must  be  brought  much  farther 
down.  In  cricket,  also,  the  swing  would  stop  on  the  outward 
stretch,  but  this  is  really  a  double  motion. 

After  having  gone  down  until  you  are  near  the  ground,  bring  the 
arm  up  again  right  over  the  head  and  down  to  the  rear,  as  shown 
by  the  arrow  in  the  photograph,  and  draw  back  the  left  foot  to 
the  starting  position.  Repeat  with  the  opposite  limbs,  left  arm 
and  right  leg.  Perform  this  movement  ten  times  to  begin  with, 
throwing  more  vigour  into  it  as  times  goes  on. 


224         MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  126,  No.  24. — THE  "  ONE,  Two,  THREE  "  MOVEMENT. 

This  movement  brings  into  play  more  or  less  every  muscle  in  the 
body,  but  principally  those  of  the  chest  and  shoulder. 

Position. — Body  erect,  head  well  thrown  back,  i'eet  together, 
hands  at  sides,  palms  outwards. 

Action. — "  One":  Raise  the  hands  to  above  the  shoulders,  elbows 
well  out  and  in  line  with  the  shoulders.  This  is  starting  position 
to  the  next  action.  "Two":  Extend  arms  vertically  upward, 
hands  high  above  the  head,  rising  on  the  toes,  and  stretching  the 
whole  frame  upwards.  "Three":  From  this  position  bring  the 
arms  sharply  down  to  the  sides  by  a  circular  sweep,  falling  back 
on  the  heels.  Throughout  this  exercise  inhale  on  the  upward  move- 
ment and  exhale  on  the  downward.  While  this  may  seem  to  be 
a  difficult  exercise,  it  is  quite  easy  to  follow  if  you  make  a  point 
of  getting  into  Position  1;  then,  pausing,  stretching  to  Position  2; 
then  bringing  back  the  hands  to  sides  and  falling  back  on  heels  to 
Position  3.  Repeat  ten  times. 


MEDICAL  GYMNASTICS 


225 


FIG.  127,  No,  25. — DOUBLE  WINDMILL  MOVEMENT. 

This  is  an  exercise  somewhat  similar  to  Exercise  No.  5,  the  chief 
difference  being  that  the  arm  muscles  are  kept  perfectly  rigid  in 
this  exercise,  while  in  No.  5  there  was  flexion  and  extension  of  these 
muscles.  The  chest  muscles  are  also  worked  in  quite  a  different 
manner. 

Position. — Stretch  the  arms  down  in  front  of  the  body,  with  the 
frame  bent  well  forward  and  chin  raised. 

Action. — From  the  starting  position  lift  the  arms  high  above  the 
head,  at  the  same  time  raising  up  the  frame  by  throwing  the  weight 
of  the  body  forward  and  rising  on  the  toes.  Inhale  on  the  upward 
movement.  Now,  without  any  pause,  swing  arms  backward  in  a 
circular  motion,  allowing  the  weight  to  go  back  and  be  sustained 
on  the  heels  as  the  arms  are  brought  down.  The  circle  should  be 
described  and  the  frame  extended  as  high  as  possible.  Exhale  on 
the  downward  motion.  Perform  this  exercise  ten  times.  Take 
time,  and  do  not  rush  through  it. 

IK 


226        MANUAL  OF  PHYSIO-THERAPEUTICS 


PIG.  128,  No.    26. — SIDE-BENDING   EXERCISE — HANDS   CLASPED 
ABOVE  HEAD. 

Tliis  exercise  will  be  found  extremely  useful  for  strengthening  the 
spinal  and  abdominal  parts,  reducing  superfluous  flesh,  and  giving 
the  shoulders  a  free  swing. 

Position. — Stand  upright  with  the  arms  above  the  head,  hands 
clasped  to  sides,  and  feet  apart. 

Action. — Bend  slowly  down  to  the  left  side,  exhaling,  until  the 
hands  touch  the  left  foot,  and  in  going  down  see  that  the  hands 
describe  as  wide  a  circle  as  possible.  Then  quickly  raise  the  frame 
up  again,  inhaling  as  you  rise,  keeping  the  arms  outstretched  and 
the  muscles  firm,  and  resume  the  erect  posture.  Having  filled  the 
lungs,  after  a  momentary  pause  bend  down  similarly  in  the  opposite 
direction.  Note  that  you  should  bend  gently,  but  rise  quickly,  as 
you  thereby  relieve  the  pressure  which  is  put  upon  the  frame  in 
the  contracted  position.  Repeat  ten  times,  bending  to  the  left  and 
right  alternately. 


MEDICAL  GYMNASTICS 


227 


FIG.  129,  Xo.  27. — TRUNK-ROLLING  MOVEMENT. 

This  movemsnt  is  a  most  valuable  lower  trunk  exercise,  building 
up  every  part,  internally  and  externally,  into  ideal  condition. 

Position. — Hands  at  the  waist,  head  raised,  feet  slightly  apart. 

Action. — Incline  the  hips  slightly  backwards  and  bend  the  Lody 
forwards  until  it  assumes  a  position  at  right  angles  with  the  legs 
Then  slowly  allow  the  body  to  roll  over  to  the  left,  then  to  the  rear 
over  to  the  right,  and  then  around  to  the  starting  position  again. 
By  this  movement  it  will  be  seen  that  the  body  has  completed  a 
circle,  the  pressure  being  applied  entirely  on  the  waist-line.  This 
exercise,  if  performed  correctly,  is  sure  to  cause  some  degree  of 
dizziness,  and  to  lessen  this  it  is  advisable  to  reverse  the  movement, 
allowing  the  body  to  circle  six  times  in  one  direction  and  then  six 
times  in  the  reverse  direction.  Another  good  plan  to  prevent 
giddiness  is  to  keep  the  head  up  and  the  eyes  fixed  ou  some  object 
straight  ahead. 


228        MANUAL  OF  PHYSIO-THERAPEUTICS 


TIG.  130,  No.  28. — STEPPING- OUT  EXERCISE — ARMS  EXTENDED  IN 

FRONT. 

This  exercise  is  designed  for  loosening  the  shoiilders,  strengthening 
the  spine,  and  improving  the  carriage. 

Position. — Hands  clenched  at  chest,  shoulders  back,  chin  up,  and 
elbows  well  to  the  rear. 

Action. — Opening  the  hands,  step  out  with  the  right  foot,  stretch- 
ing the  arms  out  in  front,  throwing  the  whole  body  well  forward. 
Inhale  as  you  step  out,  the  weight  being  thrown  on  the  toes,  the 
heels  slightly  raised  from  the  ground,  the  right  leg  bent  as  shown  in 
the  photograph,  and  the  left  leg  straight.  Pause  momentarily,  and 
then  step  back  to  the  starting  position,  bringing  the  hands  to  the 
chest  tightly  closed.  Eepeat,  stepping  out  with  the  left  foot. 
Notice  that  in  this  movement  the  back  should  have  free  play,  the 
spine  being  stretched  on  the  outward  movement  and  shortened  on 
the  return.  This  may  be  done  by  throwing  the  shoulders  as  far 
back  as  possible,  thereby  forcing  in  the  small  of  the  back.  Repeat 
ten  times,  stepping  out  with  the  right  and  left  foot  alternately. 


MEDICAL  GYMNASTICS 


229 


FIG.  131,  No.  29. — UPPER  ABM  EXERCISE. 

This  is  specially  intended  for  developing  the  upper  arm. 

Position. — Stand  upright,  feet  apart,  hands  at  the  sides,  knuckles 
to  the  rear,  palms  to  the  front,  and  hands  clenched. 

Action. — -Make  the  arm  muscles  firm,  then  slowly  raise  the  fore- 
arm, right  and  left  arm  alternately,  putting  full  pressure  on  the 
biceps,  until  the  hand  is  brought  to  the  shoulder;  then  lower  again, 
keeping  even  tension  on  the  muscles.  This  gives  the  two  extremes 
of  action,  applying  the  muscle  pressure  equally  during  the  flexion 
and  extension  of  the  arms.  To  exercise  the  triceps,  when  the  hand 
is  raised  as  in  the  figure,  turn  it  round,  palm  to  the  front,  and  force 
downwards,  putting  the  greatest  pressure  on  the  downward  move- 
ment. Repeat  ten  to  twenty  times. 


230         MANUAL  OF  PHYSIO-THERAPEUTICS 


FIG.  132,  No.  30.     SHOULDER  AND  CHEST  EXERCISE — ARMS 

EXTENDED    TO    BEAR. 

This  is  very  suitable  for  correcting  round  shoulders,  the  spinal 
curvature  of  adolescence,  or  undeveloped  chest. 

Position. — Both  arms  at  sides,  arm  and  shoulder  muscles  tense, 
and  the  whole  frame  rigid.  Keep  one  foot  slightly  to  the  rear  to 
preserve  balance,  chest  out,  and  shoulders  back. 

Action. — Having  inflated  the  lungs,  raise  the  arms  slowly  from  the 
sides,  keeping  them  slightly  to  the  rear  until  they  are  high  above 
the  head,  hands  touching,  while  rising  on  the  toes  and  stretching 
the  whole  frame.  Make  a  slight  pause,  then  bring  the  arms  down 
again  to  the  rear,  and  fall  back  on  the  heels,  exhaling  as  you  go. 
(You  must  empty  your  lungs  completely.)  Keep  the  head  thrown 
well  back  on  the  upward  movement,  and  on  the  downward  move- 
ment bring  the  head  well  forward  again.  Repeat  ten  times  to  com- 
mence with.  Do  not  change  the  feet;  this  is  a  common  error,  and 
there  is  nothing  to  gain  by  it. 


MEDICAL  GYMNASTICS  231 

Rubs. 

The  Oil  Rub. — The  anointing  of  the  body  with  oil  before 
and  after  severe  exercise,  wrestling  and  the  like,  is  a  very 
ancient  practice.  The  benefit  derived  may  be  rather 
attributed  to  the  massage  than  to  the  virtue  of  the  oil,  which 
probably  merely  acts  as  an  excipient. 

The  skin  circulation  is  improved  and  fatigue  products 
driven  out  of  the  muscles  through  the  lymphatics,  and  the 
blood-flow  in  the  muscles  generally  is  improved.  In  those 
subjects  whose  skin  is  usually  dry  and  scaly  the  oil  rub  is 
usually  a  very  useful  therapeutic  measure.  Frequently, 
however,  the  underlying  cause  in  such  cases  is  hypothy- 
roidism,  and  the  daily  administration  of  a  few  grains  of 
thyroid  extract  may  be  called  for.  In  warm  climates 
radiation  from  the  skin  is  increased  by  oil-rubbing,  but  in 
cold  climates,  on  the  other  hand,  oil-rubbing  lessens  the 
tendency  to  chill  after  a  hot  bath,  as  the  oil  surface  tends 
to  keep  in  the  heat.  Lascar  seamen,  scantily  clad,  may  be 
seen  almost  any  winter's  day  in  London  or  Liverpool  docks, 
braving  the  rigors  of  our  climate,  and  this  in  a  measure  they 
are  enabled  to  do  by  the  use  of  oil  inunction.  The  effect  is 
enhanced  if  the  skin  be  well  washed  beforehand  with  warm 
water.  Copra  or  olive  or  cotton- seed  oil  are  the  best  for  the 
purpose,  animal  oils  giving  off  an  objectionable  odour. 

The  Alcohol  Rub. — This  is  greatly  in  vogue  in  America. 
It  is  usually  applied  after  some  sweating  treatment  or  a 
douche.  About  2  ounces  of  grain  spirit  are  used;  the  appli- 
cation acts  as  a  tonic  to  the  capillary  circulation  in  the  skin. 

The  Salt  Glow  or  Rub. — A  tub  of  brine  is  used  along  with 
a  supply  of  the  finest  powdered  salt.  A  handful  of  this  is 
taken,  moistened,  and  the  patient  vigorously  rubbed  with 
it,  care  being  taken  not  to  be  too  vigorous,  as  a  smart 
erythema  may  be  so  caused.  After  six  or  eight  minutes 
the  patient  is  douched  with  warm  water,  finishing  cold. 
An  oil  rub  sometimes  follows. 

Ice-Rubbing. — Ice-rubbing  is  for  such  conditions  as  sun- 
stroke and  hyperpyrexia,  being  usually  applied  to  the  back 
of  the  neck  and  surface  of  the  spine.  A  flat  lump  of  ice  of 
convenient  size  is  held  in  a  piece  of  gauze  and  rubbed  over 
the  part  with  light  friction. 


SECTION  IV 

CHAPTER  I 
THE  REST  CURE 

THERE  are  three  essential  factors  in  the  rest  cure.     These 
consist  in — 

1.  Absolute  rest  in  bed. 

2.  Isolation  from  friends,  letters,  etc. 

3.  Abundant  feeding. 

4.  Massage  and  electricity. 

Weir  Mitchell,  of  Philadelphia,  was  the  first  physician 
who  systematically  employed  these  methods  in  combina- 
tion; and  the  late  Sir  W.  S.  Playfair  introduced  the  treat- 
ment into  this  country,  and  used  it  extensively  with  great 
success. 

The  class  of  patient  in  whom  the  most  striking  results 
are  obtained  are  neurotic  individuals  of  either  sex  who  have 
become  emaciated.  Some  such  cases  have  broken  down 
from  sheer  overstrain  where  initially  there  was  not  a  big 
supply  of  nerve  energy  to  draw  upon.  Others  have  gradu- 
ally brought  themselves  into  a  condition  of  ill-health  and 
complete  nervous  exhaustion  from  cultivating  "  diet  "  fads 
or  leading  idle,  useless,  unwholesome,  if  not  vicious,  lives. 

Some  may  evidence  the  condition  known  as  "  anorexia 
nervosa,"  and  either  refuse  food,  take  very  little,  or,  worse, 
vomit  what  they  do  take  immediately  the  meal  is  finished. 
Vomiting  may  alternate  with  diarrhoaa.  The  emaciation  is 
often  slow  in  such  cases,  but  the  ultimate  condition  of  the 
patient  is  practically  skin  and  bone;  in  other  words,  at 
the  commencement  of  the  "  cure  "  such  patients  are  fre- 
quently in  a  condition  of  the  most  profound  emaciation. 

232 


THE  REST  CURE  233 

The  following  weights  are  instances : 

Female,  aged  22  ;5  feet  8  inches),  weight,  5  stone  12  Ibs. 
Male,  aged  24  (5  feet  6  inches),  weight,  7  stone  1  Ib. 
Male,  aged  23  (6  feet  2  inches),  weight,  8  stone  3  Ibs. 

Such  patients  are  usually  markedly  anaemic,  listless, 
apathetic,  depressed,  if  not  tearful;  the  skin  is  loose  and 
dry,  and  mind  and  body  are  enfeebled  to  the  last  degree. 

While  they  occasionally  resent  the  confinement,  and 
protest  at  the  freqrent  feeding  for  the  first  day  or  two, 
they  soon  become  accustomed  to  the  routine,  especially 
if  provided  with  a  cheerful  and  tactful  nurse.  Any  in- 
subordination, if  firmly  dealt  with  at  the  start,  usually 
ceases  very  speedily,  and  reasoning  with  a  patient  may 
often  do  much  to  this  end. 

1.  Rest.  —  In  regard  to  this  factor,  it  cannot  be  too 
forcibly  insisted  that  the  rest  must  be  complete.  For  from 
four  to  eight  weeks,  or  even  longer  in  severe  and  slowly 
progressing  cases,  the  patient  must  be  kept  in  bed  without 
intermission,  night  and  day,  only  leaving  it  morning  and 
evening  to  be  placed  on  another  bed  or  couch  while  the  first 
bed  is  being  made. 

In  severe  cases  a  bed-pan  must  be  used.  Food  must  be 
cut  up  or  suitably  prepared,  and  neither  reading,  writing, 
nor  sewing  must  be  allowed. 

The  ennui  resulting  from  this  severe  regime  is  not  so 
great  as  one  might  expect.  If  good  progress  is  being  made, 
the  patient  dozes  or  sleeps  a  great  deal  during  the  day, 
and  two  hours'  massage,  some  galvanism,  and  frequent 
meals,  go  far  to  fill  up  the  waking  time. 

Any  relaxation  of  the  rules  will  depend  entirely  on  the 
progress  made;  but  in  a  case  of  moderate  severity  which 
is  doing  well  some  light  reading,  such  as  the  daily  papers, 
Punch,  or  pictorials,  may  be  allowed  at  the  end  of  the  third 
week,  and,  later,  sewing  or  an  unexciting  novel.  Gradually 
a  little  sitting  up  in  the  afternoon  may  be  also  permitted. 
This  period  is  gradually  lengthened,  and  at  the  end  of  the 
sixth  week  change  to  another  room,  or  a  walk  on  a  verandah, 
may  be  allowed. 


234        MANUAL  OF  PHYSIO- THERAPEUTICS 

A  large  airy  room,  well  lighted,  with  a  south  exposure, 
is  best  for  such  cases.  A  night  and  day  nurse  may  be 
required,  but,  generally  speaking,  it  is  best  to  have  the  same 
nurse  sleeping  in  the  patient's  room  or  a  dressing-room, 
and  a  special  masseuse  visiting  twice  daily  and  temporarily 
relieving  the  nurse. 

Too  much  importance  cannot  be  laid  on  the  choice  ot 
the  nurse.  Great  judgment  is  needed  in  this  particular, 
and  the  success  or  failure  of  the  "  cure  "  will  largely  depend 
on  the  nurse's  temperament  and  capacity.  She  must  be 
possessed  of  a  high  degree  of  patience,  and  her  sympathy 
must  be  tempered  with  discretion. 

2.  Isolation. — This  is  essential,  and  must  for  the  first  four 
weeks  be  absolute.     To  attempt  to  carry  out  this  treatment 
in  the  patient's  own  home  is  worse  than  useless.     The  place 
matters  little  apart  from  this,  and  provided  the  immediate 
environment  of  the  patient  is  cheerful  and  peaceful,  a  good 
nursing  home  or  hydropathic  sanatorium  is  equally  suitable. 
No   letters   must   be   written   or  received,    and   no   person 
permitted  to  enter  the  patient's  room  except  the  physician, 
nurse,  masseuse,  and  the  maid  who  cleans  it  and  attends 
to  the  fire. 

3.  Feeding. — As    regards    diet,    the    line    adopted   is    an 
ample  supply  of  appetizing,  easily  digested  food  at  regular 
but   frequent   intervals.     Where   the   patient   is   very   low 
down  and   digestion  much  enfeebled,  a  start  has  often  to 
be  made  with  milk  or  peptonized  milk.     To  some  patients 
this  is  distasteful  in  the  extreme,  while  others  are  com- 
pletely   upset    by    it,    acquire   a    dirty    tongue,    and    lose 
weight. 

The  addition  of  barley  or  lime  water  sometimes  helps 
matters,  but  to  those  who  have  "  the  indigestion  of  fluids  " 
described  by  Fothergill — in  other  words,  a  degree  of  gastric 
myasthenia — a  more  solid  diet  is  better  suited.  A  beginning 
can  be  made  with  chicken  puree,  creamed  fish,  plasmon 
cream,  and  rusks,  and  the  patient  gradually  worked  up 
to  a  full  diet.  All  drugs  are  best  avoided,  particularly 
digestive  enzymes,  etc. ;  at  the  most,  some  mild  aperient 
medicine  may  be  required  at  first,  as  ,\  grain  calomel  nightly, 
while  milk  is  taken. 


THE  REST  CURE  235 

The  following  is  a  typical  diet  for  such  a  patient : 

7.30  a.m.     Cafe  au  lait  and  bread  and  butter. 

8.30  a.m.  Tea  or  cocoa,  with  cream  or  milk;  two  fried 
sole  fillets;  toast  and  butter;  jam  or  marma- 
lade ad  lib. 

10  a.m.        A  glass  of  milk  and  rusk. 

12  noon.      A  whole,  cup  of  beef- tea. 

1.15  p.m.  A  large  helping  of  chicken  or  pheasant, 
vegetables,  and  milk  pudding. 

3  p.m.          A  cup  of  Benger's  food — ^  pint. 

4.30  p.m.  Tea,  biscuits,  and  bread  and  butter,  and  a 
boiled  egg. 

6  p.m.          A  cup  of  beef- tea. 

7,30  p.m.  A  large  plate  of  meat,  vegetables,  and  pudding, 
as  at  lunch. 

10  p.m.        A  glass  of  hot  milk  and  a  biscuit. 

The  nurse  must  see  that  the  meals  are  served  regularly, 
and  should  also  keep  a  careful  record  of  how  much  the 
patient  takes. 

It  is  best  to  avoid  alcohol  in  any  form,  malt  liquors 
usually  increasing  the  tendency  to  biliousness.  Tea  and 
coffee  should  both  be  used  sparingly,  and  no  after-dinner 
coffee  taken.  The  drinking  of  J  pint  of  milk  at  each  meal 
should  be  encouraged,  especially  if  milk  is  well  borne  by 
the  patient.  Sanatogen  may  be  at  times  added  to  it,  or 
Wander's  Ovaltine,  which  many  people  find  very  palatable. 
The  food  value  of  milk  puddings  may  be  further  increased 
by  adding  casein  .powder  in  the  form  of  plasmon,  or  the 
like. 

If  the  milk  is  found  not  to  be  easily  digested,  raw-meat 
juice  may  be  given  several  times  a  day  between  meals. 

The  patient  is  usually  weighed  once  a  week,  or  sometimes 
oftener;  but  care  must  be  taken  in  many  cases  to  keep  the 
weight  a  secret,  as  some  patients  are  unduly  depressed  if 
there  is  a  loss  of  weight  or  the  gain  is  slow;  while  in  female 
patients,  if  the  gain  be  rapid — say  6  pounds  in  one  week— 
they  may  refuse  to  eat  so  much  in  case  they  get  too  stoiit  ! 
This  is  by  no  means  unusual. 

The  food  is  gradually  diminished  during  the  last  week. 


238       MANUAL  OF  PHYSIO-THERAPEUTICS 

Hale- White  and  Spriggs  have  carefully  investigated  the 
metabolism  of  a  patient  during  the  rest  cure.  The  food 
supplied  during  an  eight  weeks'  course,  and  the  urine  and 
faeces,  were  carefully  weighed  and  measured.  At  the  com- 
mencement the  patient's  weight  was  6  stone  4  pounds,  and 
the  gain  in  weight  was  30  pounds.  The  physiological  heat 
value  of  a  day's  food  was  found  to  be  5,300  calories.  The 
daily  average  intake  of  fat  was  268-69  grammes,  and  96-5 
per  cent,  was  absorbed.  The  absorption  of  nitrogen  was 
found  to  be  very  complete  during  the  course,  only 
661  grammes  being  unabsorbed.  It  was  found,  however, 
that  after  making  due  allowance  for  nitrogen  in  urine, 
sweat,  and  catamenia,  there  was  still  10  per  cent,  un- 
accounted for,  the  explanation  being  either  that  these  were 
more  concentrated  at  the  end  of  the  treatment,  or  that  the 
nitrogen  was  laid  up  in  the  form  of  some  compound  more 
nitrogenous  than  proteid. 

4.  Massage. — The  object  of  the  massage  is,  of  course,  to 
take  the  place  of  normal  physical  exercise,  improve  the 
circulation,  and  hasten  the  removal  of  waste  products 
from  the  tissues.  The  whole  body  is  treated,  with  the 
exception  of  head  and  face. 

Beginning  the  first  day  with  ten  minutes  morning  and 
evening,  the  amount  is  rapidly  increased  up  to  an  hour 
twice  daily  at  the  end  of  the  first  week,  and  is  maintained 
at  that  until  the  patient  begins  to  move  about  a  little.  It 
may  then  be  gradually  decreased  until  exercise  is  taken 
freely.  The  immediate  effect  of  massage  is  drowsiness  and 
some  degree  of  hunger,  so  that  it  is  well  to  follow  the  massage 
with  some  light  form  of  meal.  The  patient  is  then  allowed 
to  sleep  for  an  hour,  the  room  being  darkened.  With 
female  patients  the  massage  to  the  abdomen  is  omitted 
when  the  period  comes  on. 

Faradism  may  be  combined  with  the  massage,  and  makes 
a  pleasant  change,  some  patients  much  preferring  the 
electrical  massage.  In  certain  cases  central  galvanism  is 
beneficial,  and  we  have  seen  a  good  many  cases  get  benefit 
from  the  high-frequency  auto-condensation  couch  in  the 
later  stages,  provided  the  necessary  apparatus  be  near  at 
hand  in  the  same  building. 


THE  REST  CURE  237 

As  regards  bathing,  the  limbs  of  the  patient  should  be 
sponged  daily  seriatim  with  cold  or  tepid  water,  and  dried 
off  with  a  rough  towel.  In  the  later  stages  a  morning  spray 
is  most  beneficial,  provided  there  be  a  good  reaction. 

The  results  of  this  somewhat  remarkable  treatment  are 
equally  remarkable,  and  the  improvement  in  physical 
health  and  gain  in  weight  often  perfectly  astonishing.  A 
very  usual  increase  in  weight  during  a  six  weeks'  course  is 
1|  to  2  stone.  Hale- White  records  a  gain  of  as  much  as 
9  pounds  12  ounces  in  one  week,  and  Graham  Brown  of 
9  pounds — the  latter  with  milk  alone.  These  are  excep- 
tional, and  one  should  be  perfectly  satisfied  with  a  steady 
gain  of  from  3  to  5  pounds  per  week. 

As  in  the  results  of  gastro-enterostomy  for  dyspeptic 
conditions,  the  thinner  the  patients  are  at  the  start  the 
more  striking  is  the  gain  in  weight.  Indeed,  the  patients 
who  benefit  most  in  every  way  are  the  absolutely  emaciated, 
worn-out  neurasthenics.  Fat,  hysterical  types,  in  whom  the 
mental  element  predominates,  do  not  improve  to  the  same 
extent;  indeed,  the  gain  in  weight  may  become  a  mere 
added  encumbrance.  Any  organic  gastric  trouble,  such  as 
an  ulcer  which  bleeds,  or  enteritis,  is  a  bar  to  success; 
but  gastralgia  and  neuralgias  of  many  regions  disappear 
like  magic  in  the  vast  majority  of  cases. 

Romberg  defined  "  pain  "  as  "  the  prayer  of  a  nerve 
for  healthy  blood  " ;  if  a  superabundant  supply  of  healthy 
blood  is  forthcoming,  the  pain  goes. 

If  the  patient  has  drug  habits,  the  usual  difficulties  have 
to  be  contended  with;  but  provided  the  habit  is  broken 
off,  they  do  well. 

While  some  weeks  may  pass  before  the  patient  is  inclined 
or  able  to  take  a  great  deal  of  exercise,  still,  in  the  large 
majority  of  cases,  at  the  end  of  the  course  the  patient  is  in 
excellent  health.  Relapses  do  occur,  but  much  will  depend 
on  the  after-care  of  the  patient.  A  sea  voyage  or  stay  in 
a  high  altitude,  as  in  Switzerland  or  at  a  high,  bracing  place 
like  Buxton  or  Ben  Rhydding,  is  very  desirable. 


238        MANUAL  OF  PHYSIO -THERAPEUTICS 


The  Annual  Cure. 

It  is  probable  that  at  no  time  in  the  history  of  mankind 
has  an  annual,  or  at  any  rate  periodic,  cure  been  more  needed 
than  at  the  present  day.  Never  was  the  struggle  for 
existence  keener  or  the  pressure  of  life — and  more  especially 
city  life — so  great.  The  Great  War  from  which  we  have 
hardly  emerged  has  aged  most  people,  and  has  been  an 
enormous  strain  on  their  vital  energy,  even  in  those  past 
middle  life  who  have  not  been  actively  engaged  in  the 
combatant  ranks.  During  the  war  we  have  had  strikes  of 
short  duration,  and  since  the  armistice  the  epidemic  of 
these  which  has  broken  out  has  been  an  immense  addition 
to  the  worries  of  the  average  business  man.  This  may  be 
considered  as  a  strain  superimposed  on  the  ordinary  factors 
which  go  to  damage  a  man's  health,  such  as  overeating 
and  drinking,  late  hours,  and  lack  of  proper  exercise  and 
amusement. 

These  all  tend  to  produce  the  congeries  of  symptoms 
known  as  neurasthenia — a  condition  almost  unknown,  and 
certainly  unrecognized,  before  the  introduction  of  the  rail- 
way, the  telegraph  and  telephone,  and  the  joyous  auto- 
mobile. People  get  this  affection  in  all  degrees  up  to  acute 
neurasthenia,  and  we  describe  them  as  "  needing  a  change," 
"  run  down,"  "  below  par,"  or  say  they  "  have  been  over- 
doing it." 

The  individual  may  be  of  either  sex  ;  a  votary  of  pleasure 
or  one  who  shuns  amusement,  but  whose  mind  is  never  at 
rest;  constantly  engaged  in  the  pursuit  of  wealth;  or  the 
person  may  be  a  man  with  a  highly  prosperous  business, 
with  various  branches  and  departments,  numerous  managers, 
sub-managers,  and  clerks.  Suddenly  his  right-hand  man 
goes  down  with  typhoid  or  pneumonia,  and  he  is  left  for 
six  weeks  or  more  to  do  practically  two  men's  work. 

During  this  time,  possibly,  a  coal  famine  occurs,  embar- 
rassing his  business  very  materially,  and  we  may  further 
imagine  that  there  is  money  stringency,  and  that  in  this 
threefold  manner  his  ordinary  normal  daily  worries  are 
multiplied  tenfold.  The  strain  of  the  position  is  soon  felt 


THE  REST  CURE  239 

even  by  an  ordinarily  healthy  man:  the  telephone  bell 
becomes  a  continual  jar  on  his  nerves ;  the  telegrams  pouring 
in  are  just  so  many  worries  clamouring  at  the  door;  he 
becomes  irritable  and  hasty  in  temper,  flies  into  a  passion 
at  a  moment's  notice  about  what  he  would  usually  con- 
sider a  trifle ;  noises  ordinarily  unnoticed,  such  as  the  banging 
of  doors  and  whistling  of  trains,  jar  acutely  on  his  nerves; 
appetite  fails;  and  finally  sleep  goes  too.  The  appetite 
may  be  flogged  on  by  sherries  and  bitters,  sleep  may  be 
coaxed  by  bromides  and  the  newest  hypnotics,  his  acuteness 
of  care  and  anxiety  may  be  dulled  by  the  free  use  of  alcohol ; 
but,  for  the  time,  a  physical  and  mental  breakdown  has 
occurred  which  no  drug  can  cure,  for  which  "  tonics  "  are 
useless,  and  nothing  but  complete  removal  from  the  field  of 
labours,  with  rest  and  a  thoroughly  wholesome  natural  life, 
can  restore  such  an  individual  to  his  usual  good  health. 
Under  such  conditions  many  men  go  off  for  a  month's 
golfing  holiday,  and  might  do  much  worse;  but  if  thoroughly 
disordered  and  broken  down,  as  such  cases  often  are,  there 
is  little  inclination  for  much  physical  exercise;  if  this  be 
taken  to  any  extent,  they  become  unduly  fatigued,  the 
bottle  is  once  more  resorted  to,  and  the  last  state  of  the 
unfortunate  individual  may  be  worse  than  the  first.  It  is 
in  such  circumstances  that  a  health  resort  of  some  kind, 
with  proper  medical  care,  may  be  of  infinite  value,  and  stay 
the  advent  of  general  paralysis  of  the  insane,  or  some  other 
form  of  organic  disease. 

One  may  cite  another  case.  A  woman  passes  through 
a  time  of  great  strain  and  difficulty.  She  may  have  the 
trying  task  of  nursing  a  husband  or  near  relative,  and  have 
gone  through  the  physical  labour  and  vigils  entailed  with 
the  additional  emotional  excitement,  swayed  by  hopes  and 
fears,  and  forgetful  of,  or  at  any  rate  denying  herself,  what 
everyone  requires  in  the  way  of  fresh  air  and  rest  when 
assaying  this  arduous  task.  Thus,  whatever  the  event  be 
for  the  patient,  the  nurse  grows  pale  and  thin,  and  looks 
weary  and  bloodless.  She  eats  little  and  digests  less,  and, 
getting  tired  on  the  slightest  exertion,  becomes  emotional 
and  mentally  depressed.  Here,  again,  drugs  are  quite 
useless.  Change  of  environment  and  removal  from  the 


240         MANUAL  OF  PHYSIO-THERAPEUTICS 

scene  of  her  recent  labours  and  struggle  are  essential,  and 
a  month  or  so  spent  in  a  judiciously  chosen  health  resort 
under  medical  care  and  advice  may  save  her  a  lifelong 
invalidism.  Many  parallel  cases  might  be  cited,  but  these 
will  suffice. 

Of  cures  and  health  resorts  the  Continent  formerly  offered 
an  immense  variety;  but  the  war  has  changed  many  things, 
and  it  is  not  likely  that  British  people  will  for  many  a  day 
care  to  visit  the  highly  developed  German  resorts  formerly 
so  much  in  vogue.  There  remain  the  French  and  Swiss 
resorts,  but  it  has  to  be  borne  in  mind  that  many  of  these 
are  closed  in  the  winter- time,  and  the  journey  to  reach  them 
may  be  long  and  tedious,  as  well  as  expensive,  the  fatigue 
but  serving  to  aggravate  the  patient's  condition  and  further 
delay  a  cure.  One  has  to  bear  in  mind  also  that  on  arrival 
there  is  often  no  English  physician,  not  always  even  an 
English-speaking  one,  so  that  there  is  difficulty  in  estab- 
lishing that  mutual  confidence  which  must  exist  between 
patient  and  doctor  if  good  results  are  to  be  attained. 

Thus  the  invalid  is  now  often  well  advised  to  consider 
our  home  resorts,  and  such  highly  equipped  bathing-places 
as  Bath,  Buxton,  and  Harrogate,  or  one  of  the  several  well 
organized  and  equipped  hydropathic  institutions  which  have 
been  built  in  this  country. 

Unfortunately,  the  word  "  hydropathic  "  is  at  once  dis- 
pleasing to  some  people,  perhaps  from  some  unfortunate 
experience  or  from  report  of  others.  There  is  a  thought 
of  a  crowd  of  noisy  people  who  are  rather  aggressive,  and 
consider  contemporaneous  residence  under  the  same  roof 
as  an  ample  introduction,  which  more  staid  and  reserved 
people  resent. 

Most  of  them,  furthermore,  have  no  licence.  Then  there 
are  the  amusements,  so  called,  which  are  not  always  judici- 
ously handled.  There  are  practically  three  types  of  hydro- 
pathic establishment: 

(1)  The  variety  which  is  practically  an  indifferent  board- 
ing-house. 

(2)  The  pure  pleasure  resort,  in  which  there  is  no  pretence 
of  giving  facilities  for  diet  or  treatment ;  and 

(3)  The  best  type,  which  offers  all  the  advantages  of  the 


THE  REST  CURE  241 

modern  hotel,  and  which,  while  in  no  way  a  hospital,  is  so 
managed  and  arranged  that  the  invalid  can  lead  a  comfort- 
able life  and  get  what  he  wants  done  for  him  just  as  at  a  spa. 
We  may  briefly  sketch  the  chief  points  in  an  establishment 
of  this  nature : 

1.  The  building  should  be  of  modern  construction  and 
at  an  elevation  of  several  hundred  feet  above  the  sea. 

2.  It  should  be  situated  in  the  country,  away  from  town 
smoke,  and  preferably  in  open  moorland  or  hilly  country, 
with,  if  possible,  adequate  shelter  from  the  north  and  east. 

3.  The   building  should  face   south,   and  the  rooms  be 
arranged  to  have  a  maximum  of  south  exposure. 

4.  The  rooms  should  be  large,  airy,  and  well  ventilated, 
with  fires  rather  than  steam  radiators  for  heating,  and  be 
lit  by  electricity. 

5.  The   sanitary   arrangements   should   be   of   the   most 
modern  description  and  faultless  in  every  respect. 

6.  The  public  rooms  should  be  large,  airy,  and  sufficient 
to  accommodate  the  maximum  number  of  visitors  comfort- 
ably and  without  unpleasant  crowding. 

7.  The  corridors  should  be  wide  and  well  lighted. 

8.  The  baths  should  be  properly  equipped  with  all  modern 
hydrotherapeutic  arrangements  and  electrical  apparatus. 

9.  The  cuisine  should  be  that  of  a  first-class  hotel,  and 
proper  arrangements  should  be  made  for  the  provision  of 
such  special  invalid  diets  as  may  be  required  from  time  to 
time. 

10.  A    qualified   physician    should    be    available    in    the 
establishment,    with    special   experience   in   this   particular 
department  of  medical  work.     The  advantage  to  the  health- 
seeker  of  having  a  reliable  physician  within  call  is  obvious; 
whilst  the  assistance  to  the  physician  of  having  patients 
collected    near    his    immediate    observation,    especially    in 
unusually  difficult  and  obscure  cases,  is  very  great.     This  is 
an  advantage  from  which  the  ordinary  medical  attendant 
is  necessarily  debarred.     It  has  been  the  writer's  experience 
on  not  a  few  occasions  to  have  patients  sent  to  be  treated 
by^hydrotherapeutic  measures  for  some  special  conditions, 
and  to  find  after  a  week  or  two  of  careful  observation  that 
the  cause  of  the  patient's  ill-health  was  something  widely 

16 


242         MANUAL  OF  PHYSIO-THERAPEUTICS 

different,  and  the  special  conditions  referred  to  by  the 
medical  man  merely  symptoms  of  a  much  more  serious 
disease. 

11.  On  the  essential  need  for  good  management  in  every 
department  it  is  needless  to  dwell,  for  the  same  applies  to 
any  house,  hotel,  or  public  establishment. 

The  Use  of  Drugs  in  "  Cure  "  Establishments.— As  patients 
placing  themselves  under  the  care  of  a  spa  physician,  or 
coming  to  take  a  "  cure,"  have  often  been  already  treated 
with  almost  every  known  drug  in  any  way  applicable  to 
their  particular  condition,  it  is  plainly  the  reverse  of  common 
sense  to  continue  medication  which,  after  careful  trial,  has 
produced  no  benefit.  The  manifest  object  in  coming  to  a 
"  cure  "  establishment  is  to  try  what  can  be  done  by  natural 
methods.  It  is  well,  therefore,  to  start  fair  and  avoid  con- 
fusion of  issues.  There  must  arise  from  time  to  time  special 
circumstances  under  which  the  prescription  of  some  drug 
is  desirable  or  even  essential,  and  no  blind  adherence  to  any 
special  form  of  treatment  can  be  expected  to  lead  to  the 
best  results.  An  open  mind  and  eclecticism  in  method  are 
always  best;  but  patients  who  arrive  with  bundles  of  pre- 
scriptions and  bottles  of  physic  are  at  the  very  start  best 
advised  to  put  away  the  former  and  throw  away  the  latter, 
commencing  their  treatment  de  novo.  Otherwise  intellects 
are  confused,  and,  if  the  invalids  improve,  it  is  impossible 
to  say  what  is  doing  them  good. 

One  of  the  most  important  factors  in  the  "  cure  "  at  any 
establishment  is  the  attitude  of  the  patient  himself.  Hope- 
fulness in  regard  to  his  case  is  of  course  essential,  but, 
in  addition,  the  invalid  visitor  must  be  freed  from  all 
mental  excitement,  and  from  the  cares  and  vexations  con- 
nected with  his  home  or  business.  So  far  as  is  possible 
he  must  leave  all  these  behind  him,  and  reports  and  letters 
from  managers  or  partners  should  be,  if  possible,  interdicted. 
A  man  who  endeavours  to  combine  his  "  cure  "  with 
negotiations  for  the  purchase  of  a  large  estate  or  a  "  bull  " 
operation  in  copper  is  wasting  his  time  and  money,  and 
stultifying  himself  and  the  physician  under  whose  charge 
lie  lias  placed  himself.  The  financial  column  in  the  daily 
paper  should  be  studiously  avoided. 


THE  REST  CURE  243 

Indeed,  the  visitor  in  search  of  health  cannot  do  better 
than  lay  to  heart  the  old  Roman  inscription  on  the  baths 
of  Caracalla : 

"  Curge  vacuus  hunc  adeas  locum 
Ut  morborum  vacuus  abire  queas, 
Hie  euhn  non  curatur  qui  curat."* 


The  Sea  Voyage. 

For  certain  disabilities  nothing  is  more  pleasant  or  effective 
as  a  cure  than  a  sea  voyage.  The  author  spent  several 
years  of  his  earlier  life  at  sea  compulsorily,  and  with  the 
greatest  benefit.  There  is  no  doubt  but  that  when  a  patient 
is  run  down  from  nervous  strain  metabolism  is  poor,  and 
there  is  always  a  tendency  to  drop  weight  while  ashore; 
the  complete  change  of  conditions  to  sea  life,  with  the 
tendency  to  laze  and  take  things  easily,  does  a  very  great 
deal  of  good.  Care  in  the  choice  of  route  and  avoidance 
of  too  long  trips  and  too  long  stretches  of  tropical  weather 
is  highly  requisite.  It  is  to  be  feared  that  every  physician 
who  recommends  a  sea  voyage  does  not  bear  in  mind  the 
fact  that  the  seasons  in  other  climes  are  not  as  our  own. 
Certainly  fast  steamships  do  not  tarry  in  the  doldrums  after 
the  manner  of  the  "  wind  jammer,"  but  if  several  of  the 
ports  of  call  are  in  the  tropical  or  semi-tropical  zone,  the 
time  spent  there  may  undo  all  the  good  of  the  voyage  from 
the  debilitating  effect  of  the  heat,  and  there  is  also  the 
possibility  of  a  malarial  infection. 

Perhaps  the  two  ideal  voyages  are  to  the  Cape  and  back 
in  an  intermediate,  slower,  but  more  restful  than  a  mail- 
boat,  and  to  Rio  or  Buenos  Ayres.  Here  we  have  just 
enough  ports  of  call  en  route  to  add  interest  to  the  voyage, 
and  have  also  a  good  long  sea  stretch,  but  never  more  than 
fourteen  days  out  of  touch  with  land.  This  is  important 
as  regards  fresh  provisions,  and  keeps  up  the  interest. 

For  certain  philosophic  subjects  the  sailing-ship  voyage 
may  be  preferred,  to  Australia  being  the  usual  one;  but, 

*   "  Light  of  heart  approach  the  shrine  of  health, 
So  shalt  thou  leave  with  body  freed  from  pain ; 
For  here's  no  cure  for  him  who's  full  of  care." 


244         MANUAL  OF  PHYSIO-THERAPEUTICS 

of  course,  here  monotony  may  be  very  trying  and  the 
cuisine  be  too  much  of  the  tinned  and  "  harness  cask  " 
variety. 

Neurasthenics  usually  improve  very  greatly,  losing  their 
irritability  and  eating  well.  As  regards  sleep,  there  are 
always  drawbacks  on  a  ship.  Many  people  get  quickly 
accustomed  to  noises,  but  all  do  not.  There  are  many 
unusual  noises  on  a  ship  for  the  landsman — the  half-hourly 
clink  of  the  bell  and  cry  of  "  All's  well  "  from  the  lookout, 
changing  of  watches,  the  rattle  of  the  ash-bucket  gear  from 
the  stokehold,  and  even  the  dreary  haunting  sound  of  the 
fog-horn  at  times. 

Few  people  can  sleep  with  the  last  going  every  three 
minutes,  but  this  mostly  happens  at  the  very  beginning, 
before  we  are  clear  of  the  Channel,  or  on  the  return.  The 
afternoon  siesta  on  a  deck  chair  or  down  below  is  sometimes 
disturbed  on  a  crowded  ship  by  a  tribe  of  noisy  children, 
but  that  is  a  minor  matter.  The  general  tendency  is 
towards  a  new  philosophy,  the  cheerfulness  and  joviality  of 
most  sea-faring  folk  being  rather  infectious. 

People  who  lead  open-air  lives  at  home  and  who  are 
accustomed  to  sport  do  not  take  very  well  to  the  sea  life, 
and  join  the  crowd  of  inquirers  who  periodically  ask  the 
captain  when  he  expects  to  "  get  there  "  or  sight  land. 

Sea-sickness  has  to  be  remembered,  and  may  be  very 
distressing,  but  we  have  known  few  people  who  did  not 
get  accustomed  to  the  roll  or  pitch  of  a  ship  after  three  or 
four  days,  and  modern  liners  are  so  vast  and  so  well  designed 
nowadays,  with  bilge  keels  and  so  forth,  that  with  any  luck 
very  little  rolling  or  pitching  is  experienced  from  port  to 
port. 

As  a  sequel  to  a  rest  cure  nothing  can  be  finer  than  a 
six  or  eight  weeks'  sea  voyage.  It  removes  the  atmosphere 
of  the  sick-room  and  brings  the  patient  back  very  often 
quite  metamorphosed. 

As  a  therapeutic  measure  it  is  not  to  be  forgotten  when 
the  physician  is  baffled  by  the  slowness  of  a  nerve  case  in 
getting  under  way  to  a  cure. 


CHAPTER  II 
OPEN-AIR  SANATORIA  FOR  CONSUMPTION,  ETC. 

JUST  at  the  close  of  the  last  century  the  public  was  stirred 
by  an  article  in  one  of  the  monthly  reviews,  written  by  a 
"  cured  "  consumptive,  greatly  belauding  the  open-air  cure 
of  phthisis  pulmonalis  as  carried  out  by  Dr.  Walther  at 
Nordrach,  in  the  Black  Forest.  Perhaps  the  article  was 
written  with  more  zeal  than  discretion,  the  writer  being  a 
special  pleader  owing  to  his  own,  it  is  to  be  feared, 
temporary  resuscitation. 

It  is  not  too  much  to  say  that  a  great  impulse  was  given  to 
the  open-air  treatment  of  tuberculosis  by  this  article,  however. 

One  is  old  enough  to  recall  the  treatment  in  vogue  for 
consumptive  cases  at  that  time  and  just  a  few  years  before. 
If  the  patient  remained  in  this  country  he  was  kept  in  a 
warm  "  sick-room  "  in  winter,  and  given  an  occasional 
change  "down  to  the  parlour";  if  he  was  possessed  of 
means  he  was  sent  abroad  to  Egypt,  the  Riviera,  or  Cape 
Colony. 

The  treatment  of  such  cases  in  hydropathics  was  then 
carried  out  frequently,  and  their  transit  in  crowded  passenger 
steamers,  possibly  sharing  the  same  cabin  with  three  other 
passengers — portholes  closed — was  a  positive  scandal  in 
the  view  of  our  present  knowledge  and  practice. 

After  1900  sanatoria  started  to  be  erected  all  over  the 
country,  and  overmuch  was  expected.  The  idea  seemed  to 
exist  that  any  case  who  was  made  to  keep  his  lungs  dis- 
tended with  fresh  air  and  his  stomach  with  food  had  a 
good  prospect  of  cure.  The  fallacy  of  this  has  been  demon- 
strated, and  we  are  now  more  discerning  and  less  optimistic. 

The  sanatorium  is  an  essential  establishment  for  the 
open-air  treatment  of  cases  of  pulmonary  tuberculosis  for 

245 


246         MANUAL  OF  PHYSIO-THERAPEUTICS 

which  there  is  a  reasonable  prospect  of  a  cure.  It  is  unfair 
to  send  cases  which  are  really  hopeless,  if  not  moribund— 
unfair  to  the  individuals  themselves  and  to  the  inmates  of 
the  sanatorium. 

Cases  that  are  seriously  ill  are  better  treated,  at  any  rate 
at  first,  in  a  nursing  home  or  in  their  own  home  under 
skilled  medical  supervision.  The  purpose  of  the  sanatorium 
is  to  receive  phthisical  patients  in  any  stage  which  affords 
a  reasonable  prospect  of  a  cure,  and  it  is  important  to  decide 
whether  there  is  sufficient  power  of  reaction  to  render  an 
open-air  life  practicable  without  doing  the  patient  harm. 

Further,  a  sanatorium  is  a  place  for  tubercular  patients, 
and  such  patients  only.  Convalescents  and  those  who  are 
merely  run  down  need  not  submit  to  the  somewhat  severe 
regime  necessarily  enforced,  nor  subject  themselves  to  the 
risk  of  infection  which  undoubtedly  exists. 

The  treatment  at  a  sanatorium  consists  in  the  careful 
regulation  of  each  patient's  daily  life  in  all  its  details.  The 
objective  is  to  enable  him  to  stand  a  life  in  the  open  air  in 
any  weather,  hardening  him  to  exposure  by  all  possible 
means,  such  as  hydropathic  measures  and  hyperalimenta- 
tion.  Exercise  is  regulated  according  to  the  special  state 
of  his  health  on  the  day  and  the  weather  prevailing.  Often 
treatment  begins  by  rest  in  bed  until  it  is  found  there  is 
no  temperature  running.  Then  it  has  to  be  established 
that  exercise  does  not  cause  a  temperature.  There  is  a 
certain  ritual  always  laid  down  to  prevent  infection,  for 
even  frankly  tubercular  cases  may  get  fresh  infection  or 
mixed  infection,  and  so  get  worse.  The  patient  is  seen  by 
the  doctor  at  least  twice  daily,  and  is  under  constant  obser- 
vation of  nurses  specially  trained  for  this  class  of  work. 
His  tendency  to  do  too  much  is  thus  restrained;  he  is 
encouraged  to  be  hopeful  and  not  to  do  too  little;  he  is  not 
allowed  to  "  snug  around  the  fire  "  or  shut  his  window, 
while  treatment  of  symptoms  is  prescribed  as  they  arise.  The 
tendency  of  patients — many  patients — to  under-ventilate 
and  overheat  their  rooms  has  constantly  to  be  combated. 

The  keynote  of  the  treatment  is  open  air,  whether  the 
patient  is  in  bed  or  out  of  doors.  Many  patients  at  first 
find  this  life  very  trying;  they  may  feel  miserably  cold  and 


OPEN-AIR  SANATORIA  FOR  CONSUMPTION     247 

develop  chilblains,  and  become  mentally  depressed.  But 
in  the  vast  majority  of  cases  they  learn  to  laugh  at  their 
first  sensations  and  become  acclimatized.  It  has  to  be 
admitted,  that  some  cases  do  not  become  so,  and  these 
do  not  nourish  in  the  surroundings  of  a  sanatorium,  but 
they  are  exceedingly  rare. 

Rest  or  exercise  out  of  doors  is  practised  in  all  but  the 
worst  weather — in  sheltered  balconies,  in  the  first  instance, 
fitted  with  artificial  light  for  use  in  the  short  winter  days. 
Here  patients  may  take  their  before-meal  rest,  or  spend 
the  evening  reading  or  playing  unexciting  games.  Patients 
are  known  to  stay  out  of  doors  in  rain,  fog,  and  snow  without 
harm.  At  the  Victoria  Hospital  in  Edinburgh,  the  writer 
was  assured  some  years  ago,  it  was  not  uncommon  to  have 
patients  who  slept  out  of  doors  in  the  shelters  dug  out — in 
winter — quite  snowed  up.  At  Banchory  the  moment  the 
snow  stops  it  is  quite  usual  to  have  a  team  of  patients  in 
the  putting-green  clearing  away  the  snow,  to  commence 
putting  again,  and  overcoats  are  seldom  worn.  Dettweiler 
states  that  his  patients  stay  out  on  an  average  as  follows: 
40  per  cent,  more  than  seven  hours  a  day,  and  6  per  cent, 
ten  or  twelve  hours  a  day. 

As  regards  hydropathic  measures,  either  the  wet  sheet  is 
used  for  hardening  the  patient  or  the  cold  spray.  At 
Banchory  when  the  sanatorium  was  built  the  patients  all 
had  a  spray  apparatus  fitted  in  their  rooms. 

The  question  of  rest  and  exercise  is  one  of  the  most 
important  in  the  treatment,  and  is  adjusted  with  the  utmost 
nicety  to  each  individual  patient.  As  suggested  before, 
patients  who  are  febrile  are  kept  in  bed  with  absolute  rest. 
If  the  temperature  is  very  slight,  they  may  be  allowed  up 
in  a  chair  or  couch  in  their  own  room  or  an  open  balcony. 
As  the  temperature  becomes  normal  their  appetite  improves, 
and  usually  dyspeptic  symptoms  disappear.  Not  always 
so,  as  some  patients  are  more  or  less  chronic  dyspeptics, 
and  in  such  the  feeding  question  may  be  difficult,  and  it 
may  be  very  hard  to  get  the  adequate  amount  of  calories 
into  the  patient  daily  to  enable  him  to  gain  or  even  keep 
his  weight  and  take  active  exercise. 

When  walking  begins  it   may  be   restricted  at  first  to 


248        MANUAL  OF  PHYSIO-THERAPEUTICS 

walking  on  the  level  for  a  few  dozen  yards  only.  This  is 
gradually  increased  by  daily  increments,  and  a  little  uphill 
work  added.  The  principle  adopted  is  much  that  of  the 
ancient  who  wagered  he  would  carry  a  bull,  and  by  way 
of  training  he  started  with  a  young  bull  calf.  When  the 
beast  grew  up  he  won  the  bet. 

With  careful  daily  oversight  by  the  doctor  and  regulation 
according  to  weather  and  personal  condition,  the  patient 
gradually  increases  his  distance  and  the  amount  of  climbing. 
Most  sanatoria  have  some  arrangement  of  stages  or  finger- 
posts to  make  the  graduating  easy.'   The  walk  should  not 
be  of  the  athlete's  training  style,  but  a  leisurely  saunter 
of  about  two  miles  an  hour.      If  there  be  any  dyspnoea 
occasioned,  an  immediate  rest  must  be  taken,  and  a  halt 
also  made  if  fatigue  is  being  felt.     If  the  fatigue  is  not 
easily  recovered  from  or  if  the  pulse  keeps  quick  or  there 
is  profuse  perspiration,  then  the  walk  has  been  overdone, 
and  a  pause  for  some  days  may  be  needed.     It  is  usual  to 
have  a  rub  down  with  a  rough  towel  after  the  walk,  and 
sometimes  a  spray,  followed  by  rest.     The  longest  walk  is 
usually  taken  in  the  morning.     While  walking  is  excellent 
and  may  not  pall  so  soon  in  a  district  where  the  country  is 
pretty  and  the  patient  is  strong  enough  to  go  some  distance, 
it  must  inevitably  pall  sooner  or  later,  and  it  cannot  be 
wholly  relied  on  for  exercise  unless  the  patient  is  to  get 
bored.     Out-of-door  hobbies  of  some  sort  are  highly  desir- 
able, if  not  essential — sawing  wood,  chopping  sticks,  light 
gardening,  croquet  and  clock  golf,  photography,  and  fishing, 
though  saZmoft-fishing  must  needs  be  excluded  as  being  too 
great  a  tax  on  the  strength — if  a  catch  be  made  !     Horse- 
back exercise  and  driving  may  be  permitted  if  the  roads 
are  not  dusty,  and  cycling  on  level  ground.     Motor  cycling 
can  be  ruled  out,  but  ordinary  motoring,  if  the  dusty  days 
are  avoided,  cannot  well  be  objected  to.     For  indoor  amuse- 
ments  all    the    well-known    varieties   are   available    up   to 
billiards,  but  in  all  this  it  is  important  to  bear  in  mind  that 
the  highly  important  feature  in  many  cases,  especially  at 
the  beginning,    is  rest,   physical  and  mental,  and  exciting 
billiard    handicaps  and    auction    bridge    for    considerable 
points  may  both  do  harm. 


OPEN-AIR  SANATORIA  FOR  CONSUMPTION     249 

Patients  usually  fall  quickly  into  line  and  defer  to  the 
doctor  in  respect  to  these  matters,  many  making  a  hobby 
of  "getting  well."  But  it  is  to  be  remembered  that  at  a 
sanatorium  there  are  all  sorts  as  regards  temperament, 
and  restless  spirits  will  break  out  at  times  and  throw  caution 
to  the  winds,  with  the  inevitable  aftermath  of  a  straight 
talk  from  the  physician  in  charge  and  perhaps  a  set-back 
in  health.  One  finds  even  patients  who  do  foolish  things 
behind  the  doctor's  back,  thinking  they  are  rather  clever 
until  the  day  of  reckoning  comes. 

The  Dietary. — In  the  early  days  patients  entered  a  sana- 
torium with  tuberculosis  of  the  lung,  and  left  it  cured  or 
partially  cured,  but  with  often  dilated  stomachs. 

The  fashion  was  set  at  Nordrach  of  always  overfeeding — 
no  novelty  to  a  German,  whose  stomach  is  seldom  empty 
(in  peace-time  ?) — and  not  only  were  vast  quantities  of 
food  consumed,  but  dietetic  outrages,  such  as  mixing  Rhine 
wine  with  milk  or  taking  them  one  after  the  other,  were 
perpetrated.  These  days  are  past  and  gone,  and  while  it 
is  recognized  that,  if  possible,  there  must  be  a  certain  amount 
of  hyperalimentation  in  a  case  of  phthisis  undergoing  a  cure, 
the  pace  is  not  forced.  If  the  patient's  appetite  is  bad  he 
is  kept  at  rest  and  coaxed  into  eating,  not  made  to  take 
exercise  and  bullied  to  take  food  which  he  does  not  digest. 
A  calorie  value  of  at  least  4,000  must  be  aimed  at,  and 
5,000  if  at  all  possible.  Special  efforts  are  necessary  to 
make  the  food  appetizing,  digestible,  and  varied  in  character, 
avoiding  at  all  times  overloading  of  the  stomach,  which 
will  upset  the  liver  and  cause  depression  and  a  set-back. 
There  is  need  for  constant  co-operation  of  the  medical 
director  with  the  housekeeper.  Much  valuable  work  was 
done  by  Chapman  and  Bardswell  on  dietaries  in  tubercu- 
losis, and  the  reader  who  really  wishes  to  go  fully  into  the 
subject  cannot  do  better  than  peruse  their  book. 

In  view  of  the  tendency  in  phthisis  to  lose  weight,  there 
should  be  a  preponderance  of  fat  and  highly  nitrogenous 
food  in  the  diet,  as  there  is  need  for  rapid  constructive 
metabolism.  Milk,  cream,  and  butter  in  abundance  are 
essential,  and  the  possession  of  a  home  farm  is  invaluable 
at  any  sanatorium,  where  the  dairy  work  is  under  control 


250        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  cows  closely  observed.  Theoretically  they  should  be 
tuberculin  tested,  but  unfortunately  this  is,  in  the  opinion 
of  many  agriculturists  and  even  public  health  authorities, 
a  counsel  of  perfection,  and  if  not  done  pasteurization 
should  be  carried  out  as  a  matter  of  routine.  This  does 
not  improve  the  value  of  the  milk,  as  something  is  destroyed 
in  the  process  which  has  not  yet  actually  had  a  name 
put  to  it,  but  is  possibly  of  the  nature  of  a  vitamin — 
"that  curious  illusory  body,"  as  Professor  Halliburton 
terms  it. 

Milk  forms  such  a  very  considerable  portion  of  the  dietary, 
however,  that  unusual  care  is  called  for* 

Taking  the  day's  food  for  such  a  patient,  something  like 
the  following  arrangement  of  meals  is  usually  followed  in 
British  sanatoria : 

1.  In  early  morning,  on  waking,  milk,  hot  or  warm,  up 
to  10  or  even  15  ounces  may  be  taken.     Sometimes,  but 
not  often,  rum  is  added.     A  better  addition,  however,  is 
a  little  sodium  bicarbonate  or  sodium  citrate,  which  renders 
the  milk  more  digestible.     To  patients  who  dislike  milk, 
and  they  are  not  exceptional,  tea  made  with  milk  may  be 
given,  or  cafe  au  lait  (with  an  accent  on  the  latter  !). 

2.  At   8.30  a   substantial  breakfast  is  taken  of  fish   or 
bacon  and  eggs,  preceded  by  porridge,  and  with  at  least 
-|-  pint  of  milk  with  coffee  or  tea  or  cocoa;  toast  or  bread 
and  butter,  with  the  butter  spread  thick ;  cream  always  with 
porridge;  jam  or  marmalade,  unless  the  digestion  is  easily 
upset,  when  they  may  be  best  omitted. 

3.  As  a  snack  in  the  middle  of  the  forenoon  one  or  two 
raw  eggs  beaten  up  with  milk,  and  perhaps  a  tablespoonful 
of  brandy,  with  sugar  to  taste,  may  be  taken  not  later  than 
11.30.     This  makes  a  nice  change  from  milk,  and  is  of  high 
caloric  value.     Alternatively,  where  there  is  some  indigestion 
of  fluids,  raw-meat  juice  or  a  raw-meat  sandwich  made  with 
scraped  beef. 

4.  At   1.15  or  thereby  a  substantial  meal,   perhaps  the 
biggest  of  the   day,  should  be   taken.     Milk   soup  or  one 
made  with  beef  stock  and  peas  or  lentil  or  beans;  several 
slices  of  rather  underdone  meat  or  a  steak  and  vegetables, 
with  milk  or  crumb  pudding  and  stewed  fruit. 


OPEN-AIR  SANATORIA  FOR  CONSUMPTION     251 

5.  At  4.30  afternoon  tea  with  bread  and  butter  and  plain 
cake;  not  less  than  10  ounces  of  milk. 

6.  At  7  a  meal  much  as  midday,  with  perhaps  the  addition 
or  option  of  fish. 

7.  At  9.30  to  10  a  glass  of  hot  milk  and  perhaps  a  cracker, 
or  raw-meat  juice  or  Horlick's    or    Hooper's  milk  where 
fresh  cow's  milk  is  not  borne. 

This  dietary,  if  taken,  will  make  a  calory  value  approaching 
5,000  or  more,  according  to  the  liberality  of  the  helpings. 

Patients  should  be  warned  not  to  complicate  matters  by 
eating  chocolates  or  toffees  or  fruit  out  of  hours,  as  the 
digestion  will  be  tested  to  the  utmost  with  this,  .even  if 
ample  exercise  be  taken. 

If  the  patient  sleep  badly,  he  may  be  given  whole  beef- 
tea,  beef-juice,  Bovril,  or  malted  milk,  but  it  is  foolish  to 
wake  a  patient  for  extra  nutriment.  Some  patients  may 
be  wholly  unable  to  tolerate  it,  even  when  begun  gradually, 
either  because  they  cannot  digest  milk,  which  nauseates 
them  and  gives  them  a  filthy  tongue,  or  the  fluid  is  too 
great  for  their  capacity  and  tends  to  cause  gastric  stasis. 
It  will  be  necessary  then  to  drastically  cut  down  the  food, 
perhaps — at  first  either  eliminating  the  milk  or  using  a  milk 
diet  only,  if  that  is  best  digested  and  the  solids  cause  dis- 
comfort. With  patience  and  tact  the  dietary  will  gradually 
become  adjusted  to  the  patient's  capacity.  The  dilution  of 
milk  with  lime  or  barley  water  may  help. 

The  General  Construction  of  a  Sanatorium. — Many  of  the 
details  now  considered  essential  in  modern  hospital  con- 
struction have  to  be  carried  out  in  a  sanatorium.  The 
hospital  idea  is  paramount,  not  that  of  a  dwelling-place. 

As  far  as  is  possible,  all  rooms  for  patients  face  the  south, 
and  it  is  desirable  to  have  a  balcony  outside  at  least  a 
portion  of  them.  It  has  to  be  borne  in  mind  that  in  our 
climate,  with  many  sunless  days,  balconies  have  their  draw- 
backs, and  tend  to  make  the  rooms  themselves  sunless  and 
in  the  shade. 

Patients  who  are  constantly  out  of  doors  during  daytime 
do  not  need  a  balcony,  but  those  who  are  leading  a  more 
or  less  bedroom  existence  find  advantage  in  it.  Those  with 
experience  of  sanatorium  management  will  support  the 


252        MANUAL  OF  PHYSIO-THERAPEUTICS 

contention  that  each  section  of  balcony  should  be  partitioned 
off  by  wire  netting  or  some  such  division  from  that  belonging 
to  the  next  room,  or  various  social  difficulties  arise  if 
the  population  be  mixed  as  regards  the  sexes.  The  ad- 
ministrative quarters  can  well  be  at  the  back,  along  with 
the  kitchens,  etc.  Large  public  or  common  rooms  are  not 
to  be  advocated,  as  it  is  not  desirable  to  give  any  induce- 
ment to  patients  to  stay  indoors.  At  Banchory  there  is 
an  admirable  out-of-door  lounge,  comfortably  furnished, 
where  there  is  plenty  of  open  air,  but  no  draught. 

The  whole  building  should  face  south  or  south-east  or 
south-west  slightly.  Windows  should  be  divided  into  two 
vertical  panes,  on  lateral  hinges,  fixed  on  a  swivel  of  firm 
construction,  and  so  arranged  as  not  to  rattle.  Some 
authorities  lay  down  that  as  much  as  one-half  of  one  side 
of  any  room  should  be  made  up  of  window.  Inside  thick 
curtains  are  to  be  avoided,  as  they  are  dust-traps  and  not 
easily  cleaned.  As  many  people  do  not  sleep  easily  in 
daylight,  outside  green  blinds  of  inexpensive  kind,  easily 
cleaned,  are  necessary  in  most  cases. 

The  heating  should  be  central,  and  electric  light  is  almost 
indispensable.  As  regards  size  of  room,  this  is  less  important 
than  the  arrangements  for  easy  change  of  air.  The  old 
allowance  of  3,000  cubic  feet  of  air  per  hour  is  insufficient, 
and  should  be  greatly  increased  up  to  15,000  or  18,000  cubic 
feet  per  head  per  hour. 

The  whole  sanatorium  should  be  constructed  so  as  to 
render  cleansing  and  dusting  as  simple  as  possible.  All 
ledges  over  doors  and  windows  should  be  avoided,  cup- 
boards should  be  sunk  into  walls,  and  all  corners  rounded 
over  the  whole  cube  of  any  room.  Corridor  floors  are  best 
made  of  mosaic — the  drawback  being  it  is  rather  cold 
and  noisy — and  room  floors  of  varnished  wood,  cracks 
being  avoided  at  all  times,  and  filled  up  when  they  occur 
from  any  cause.  At  Banchory,  where  the  whole  sanatorium 
is  of  wood,  the  walls  are  simply  distempered,  and  this  is 
easily  and  inexpensively  done  after  any  patient  leaves. 
Cement  walls  are  equally  easy  to  deal  with.  On  the  whole, 
all  pictures,  however  simple,  should  be  avoided;  they  are 
dust-traps,  and  add  to  the  labour  of  cleaning  materially. 


OPEN-AIR  SANATORIA  FOR  CONSUMPTION     253 

Something  of  the  ritual  of  a  surgical  theatre  must  enter 
into  the  whole  atmosphere  in  a  sanatorium,  and  simplicity 
of  furnishing  be  aimed  at  in  every  respect. 

All  a  bedroom  requires  is  a  hospital  bed-rug  on  the  floor 
at  bedside;  sunk- in  wardrobe,  which  is  best  flush  with  the 
wall ;  and  toilet- table — washing  being  conveniently  done 
in  the  adjoining  lavatory,  except  with  acute  cases.  The 
patient  is  allowed  a  few  memories  of  home  and  friends  in 
the  way  of  photographs,  and  more  is  not  called  for  in  the 
way  of  decoration. 

Chairs  of  the  public  rooms,  dining-room,  and  outdoor 
lounge,  should  be  simple — Russian  bentwood  with  per- 
forated wooden  bottoms,  or  lounge  easy  chairs  of  strong 
canvas  or  cane.  A  maximum  of  bare  but  polished  floor 
and  a  minimum  of  rug  or  carpet  at  all  times  is  best. 

It  may  be  advisable  to  have  electric  fans  fitted  to  a  few 
rooms  to  increase  the  air  exchange  in  hot  weather  for 
patients  who  are  acutely  ill. 

A  high-pressure  sterilizer  is  almost  an  essential  in  the  out- 
fit of  the  sanatorium;  also  an  apparatus  for  stoving  bed- 
clothes, mattresses,  and  the  like. 

The  Grounds  of  the  Sanatorium. — Considerable  acreage 
around  a  sanatorium  is  desirable,  in  order  that  patients 
may  take  their  exercise  to  a  large  extent  within  them,  and 
avoid  the  public  and  often  dusty  roads.  In  a  comparatively 
limited  area  miles  of  walks  may  be  laid  out,  where  walking 
can  be  carried  out  under  a  certain  amount  of  shelter  from 
trees.  Spruces  and  larches  afford  the  best  shelter;  the  old 
idea  of  the  healthful  effects  of  the  aroma  of  pine-trees  is 
largely  a  myth,  or  at  any  rate  is  not  of  any  special  import- 
ance. Walks  should  be  modelled  on  the  Pinetum,  or 
Invalids'  Walk,  at  Bournemouth.  At  Banchory  pines 
abound,  and  there  is  admirable  shelter  all  over  the  grounds, 
and,  indeed,  for  miles  outside  of  them. 

Climatic  Element. — Undue  stress  is  not  laid  at  the  present 
time  on  the  value  of  climate  in  the  treatment  of  consumption 
in  a  sanatorium,  as  formerly.  The  successful  cure  of  the 
disease  can  be  undertaken  in  almost  any  climate  if  the 
air  be  pure  and  the  treatment  properly  carried  out. 

In  Peebles,  which  has  a  particularly  severe  winter  climate, 


254         MANUAL  OF  PHYSIO -THERAPEUTICS 

the  disease  has  almost  been  stamped  out,  and  this  as  much 
by  domiciliary  chalet  treatment  as  by  the  use  of  a  small 
sanatorium  in  the  county.  At  the  Edinburgh  Victoria 
Hospital,  lying  comparatively  low  and  near  the  sea,  the 
results  are  most  favourable ;  the  hospital  is  on  the  fringe  of 
the  city,  and  subject  to  the  "  easterly  haar  "  off  the  sea, 
and  even  smoke-clouds  with  the  wind  from  the  south-east. 
.  The  important  factor  is  the  systematic  routine  of  a 
properly  organized  and  well-conducted  institution,  with  the 
daily  observation  of  a  skilled  and  experienced  physician. 
Bardswell  and  Chapman  cite  a  case  of  a  young  lady  who 
lost  symptoms  and  got  almost  obese  in  such  an  institution, 
and  went  to  the  bad  at  once  when  travelling  in  perhaps 
more  desirable  climates. 

There  is  another  important  reason  for  curing  patients  in 
their  own  climate.  If  they  are  persons  of  independent 
means  who  can  winter  in  Egypt  and  in  the  Riviera  or 
Madeira  it  does  not  matter,  but  the  average  person,  if  he 
is  cured,  has  to  live  and  work  in  the  climate  he  was  born 
in.  The  proper  function  of  a  sanatorium  is  to  turn  out 
hardy,  healthy  people,  who  are  fit  above  the  average,  with 
a  cured  chest  lesion — not  to  produce  hothouse  plants. 

There  are  certain  subjects  with  a  tendency  to  catarrhal 
symptoms  more  particularly  who  may  not  do  so  well  on  the 
East  Coast  of  Scotland  as  in  a  drier,  milder  area  like  the 
New  Forest,  but  these  are  the  exception.  A  patient  who 
has  spent  a  year  at  a  Scottish  sanatorium  and  is  half-way 
to  the  cure  may  feel  bored,  and  do  no  harm  by  changing 
to  Davos  or  Falkenstein  for  a  while,  but  there  are  other 
factors—  -e.g.,  there  is  a  new  doctor. 

Many  patients  get  attached  to  a  sanatorium,  and  return 
periodically  for  an  overhaul,  and  perhaps  for  some  months' 
sojourn. 

As  regards  foreign  sanatoria,  the  fatigue  and  difficulty  of 
the  journey  has  to  be  borne  in  mind,  and  the  greater  expense. 
The  patient  is  also  isolated  more  than  ever  from  his  friends, 
and  visits  will  be  few  and  far  between.  Above  all,  there  is 
a  strong  objection  in  the  case  of  patients  who  are  really 
ill,  and  in  whose  case  the  odds  are  against  recovery.  It  is 
an  unnecessary  hardship  to  patient  and  friends  alike. 


CHAPTER  III 
CLIMATIC  TREATMENT 

THE  importance  of  climate  in  health  and  disease  must  not 
be  overlooked  in  the  consideration  of  the  various  forms  of 
physio-therapy.  Many  diseases  and  disabilities  are  favour- 
ably affected  by  the  right  kind  of  climate,  which  it  lies 
within  the  province  of  the  physician  to  select. 

Great  care  is  needed,  for  while  we  can  quickly  rectify 
a  prescription  on  a  hint  from  the  patient  or  the  dispensing 
chemist,  if  we  order  a  patient  to  an  unsuitable  climatic 
environment,  the  realization  on  his  part,  which  may  be 
gradual,  with  attendant  loss  of  time  and  expense,  will 
imperil  his  confidence  in  our  judgment,  and,  indeed,  may 
constitute  an  unforgivable  offence. 

If  we  consider  the  intelligentia  among  the  public,  many 
of  them  with  means  and  leisure  are  as  well  or  better  informed 
as  regards  the  suitability  of  various  health  resorts  than 
many  of  our  profession — from  practical  experience  on  their 
own  corpora  villa.  Nevertheless,  the  general  practitioner, 
whose  knowledge  at  the  present  time  must  be  encyclopaedic, 
is  often  consulted  about  health  resorts  and  where  to  get  a 
suitable  change  of  air.  Thus  his  responsibility  is  consider- 
able either  in  advising  or  condemning.  His  knowledge  can 
scarcely  be  acquired  from  books,  or,  if  so  obtained,  is  very 
different  from  practical  acquaintance  with  different  localities. 

The  word  "  climate  "  is  used  to  indicate  differences  which 
exist  between  one  place  and  another  as  regards  temperature 
and  its  variations,  as  regards  rainfall,  the  density  and 
pressure  of  the  atmosphere,  prevailing  winds,  the  chemical 
composition  of  the  atmosphere,  and  the  organic  and  inorganic 
substances  it  contains. 

One  of  the  most  important  factors  is,  of  course,  the  amount 


256         MANUAL  OF  PHYSIO -THERAPEUTICS 

of  sunshine,  and  this  has  direct  relation  to  the  distance  from 
the  Equator.     We  have — 

(1)  Hot  or  warm  climates,  extending  from  the  Equator 
to  lat.  35,  with  a  mean  annual  temperature  of  80°  F. 

(2)  Temperate  climates,  extending  from  35  to  55  degrees 
of  latitude,  and  a  mean  annual  temperature  of  60°  F. 

(3)  Cold  climates,  between   55  N.   and  the  poles,   with 
temperature  varying  from  5°  to  40°  F. 

But  for  practical  purposes  we  have  to  consider  them  in 
greater  subdivision  than  this,  and  may  class  them  into 
seven  varieties : 

1.  The  hot  climate. 

2.  The  temperate  climate. 

3.  The  cold  climate. 

4.  Insular  climate. 

5.  Maritime  climate. 

6.  Continental  climate. 

7.  Mountainous  climate. 

Hot  climates  we  seldom  prescribe ;  they  are  rather  endured 
than  sought  for  by  the  white  races,  and  have  tropical 
diseases  added  to  the  ills  which  such  flesh  is  heir  to.  On 
the  other  hand,  the  temperate  climate  is  the  healthiest  on 
the  globe,  neither  extremes  of  her  t  or  cold  being  experienced. 
Temperate  climates  lie  mostly  between  35  and  55  degrees, 
with  a  mean  temperature  of  50°  to  60°  F.  They  have  the 
four  seasons — spring,  summer,  autumn,  and  winter — and 
there  is  among  them  a  great  variety  of  local  climates,  such 
as  we  see  in  our  own  home  health  resorts. 

Cold  climates,  from  lat.  55  to  the  poles,  may  again  be 
divided  into  cold,  very  cold,  and  glacial,  but  these,  like 
hot  climates,  are  not  of  any  special  therapeutic  interest. 

Insular  climates  are  valuable  and  remarkable  for  their 
equable  seasons,  owing  to  the  surrounding  water;  the  air 
is  humid,  and  constantly  changed  by  varying  breezes. 

The  maritime  climate  is  similar.  It  is  warmer  in  winter 
and  cooler  in  summer  than  the  Continental  climate,  the 
temperature  increasing  as  we  go  inland.  The  Continental 
climate  has  a  tendency  to  extremes  of  temperature,  with 
very  cold  winters  and  hot  summers. 


CLIMATIC  TREATMENT  257 

In  mountainous  climates  we  find  the  air  rarefied  and  the 
barometric  pressure  low,  and  getting  lower  as  we  ascend. 
The  air  is  cooler  and  exceedingly  pure. 


Factors  in  Climate. 

The  Composition  of  the  Air. — In  100  volumes  nitrogen 
forms  79-00,  oxygen  20-96,  and  carbonic  acid  0«04.  As  is 
well  known,  the  percentage  of  C02  in  air  varies  greatly — 
as  much  as  from  4  to  30  vols.  in  10,000. 

The  temperature  of  the  air  has  also  a  marked  influence 
on  climate.  The  nature  of  the  surface  of  the  ground  also 
exercises  great  influence  on  the  amount  of  heat  which  is 
absorbed  and  reflected.  The  nearer  the  colour  of  the  ground 
approaches  to  white — as,  for  instance,  chalk  soil,  snow,  etc. 
—the  more  the  solar  heat  reflected  and  the  less  absorbed, 
while  with  dark  ground — earth,  grass,  and  leaves — more  is 
absorbed  and  less  reflected.  Conversely,  during  the  night 
the  ground  which  absorbs  most  heat  by  daytime  gives  out 
most. 

In  maritime  districts  the  temperature  is  so  far  stabilized, 
and  we  get  what  lesembles  an  insular  climate,  while  in 
hilly  regions  the  mean  temperature  is  low  and  there  is  often 
a  big  range  of  temperature.  In  the  Engadine  this  is  very 
marked,  it  being  necessary  to  adapt  the  clothing  carefully 
to  different  times  of  the  day  in  winter,  especially  with 
people  who  easily  catch  a  chill. 

A  further  influence  is  barometric  pressure,  for  if  this  be 
considerable  it  exercises  a  marked  influence  on  some  indi- 
viduals. It  always  increases  the  amount  of  H2O  and  C02 
exhaled  by  the  lungs,  and  may  induce  laboured  respiration; 
there  is  less  capacity  for  taking  exercise,  and  many  people 
suffer  from  depression  and  constipation.  Winds  tend  to 
purify  the  atmosphere,  and  lead  to  changes  in  temperature, 
atmospheric  pressure,  moisture,  and  light.  They  are  there- 
fore very  important  factors  in  the  climate  of  any  locality. 

The  humidity  of  any  atmosphere  varies  with  the  amount 
of  condensation  and  evaporation  which  goes  on.  As  a  rule, 
absolute  humidity  is  greatest  with  a  high  temperature,  but 
relative  humidity  is  greater  in  winter  than  summer.  When 

17 


258        MANUAL  OF  PHYSIO-THERAPEUTICS 

the  air  is  saturated  we  get  mists  and  clouds — clouds  generally 
at  average  heights,  mists  on  plains  and  in  maritime  districts. 

Rainfall  varies  enormously  in  different  parts  of  the 
habitable  globe.  It  rises  from  zero  or  near  it  at  the  Sahara 
to  nearly  400  inches  per  annum  in  Assam  and  the  Himalayas. 
In  Great  Britain  the  wettest  districts  are  Glencoe  and 
Ballaculish  and  Seathwaite  in  the  English  Lakes. 

Rainfall  is  not  necessarily  injurious  to  a  climate,  as  it 
helps  to  purify  the  atmosphere,  but  in  estimating  a  climate 
we  have  to  consider  the  amount  of  rain  per  annum,  the 
number  of  rainy  days,  the  rainy  season,  and  even  the  time 
of  day  when  rain  mostly  falls. 

In  the  treatment  of  disease  climate  is  a  specific  in  few,  if 
any,  but  a  change  of  climate  may  have  the  most  favourable 
influence,  and  in  certain  affections  a  very  few  miles  may 
make  a  lot  of  difference.  This  is  so,  for  instance,  in  asthma 
and  rheumatism.  The  situation  of  the  patient's  home  in  an 
unfavourable  locality  for  either  of  these  affections — the  effect 
on  asthma  varying  enormously  with  the  individual — may 
perpetuate  and  aggravate  the  disease,  while  a  removal  to 
a  more  suitable  environment  may  be  the  first  step  to 
recovery. 

Diseases  of  the  lungs  apart  from  pulmonary  tuberculosis 
are  favourably  influenced  by  a  mild,  moist  climate. 

The  late  Norman  Hay  Forbes  formulated  the  following 
rules  for  the  choice  of  climate  for  any  individual  patient : 

1.  Information  must  be  obtained  that  the  general  sanita- 
tion,  water,   and  food-supply   of  the  proposed  resort  are 
above  suspicion.     It  is  well  to  remember  that  a   change 
means  not  change   of  air   alone.     If  ccelum  non  anitnum 
mutant,  food  habits,  occupations,  environment,  with  mental 
occupations  and  interests,  usually  are  changed — mostly,  in 
all  probability,  with  benefit. 

2.  The  local  features  of  the  climate  should  be  ascertained 
—e.g.,  local  characteristics  of  temperature,  relative  humidity, 
rainfall  and  sunshine,   wind,  especially  local  currents  and 
shelter  from  winds,  barometric  pressure,  and  the  amount  of 
cloud. 

3.  An  important  point  at  all  times  to  bear  in  mind  is 


CLIMATIC  TREATMENT  259 

that  the  most  fundamental  point  in  the  action  of  climate 
is  its  influence  on  tissue  change. 

4.  Remember    that    different    individuals    react    quite 
differently  from  the  same  external  conditions,  and  it  is  true 
also  climatically  that  "  one  man's  meat  is  another  man's 
poison." 

5.  Therapeutically    climates    are    best    classified    on    a 
physiological   basis,   according   to   the   demands  made   by 
the  climate  for  the  production  of  heat,  which  is  another 
way  of  saying  tissue  change. 

6.  It   is   useless — indeed,    worse — to   prescribe    "a   good 
bracing  climate  "  for  a  delicate  and  weakly  convalescent, 
whose   metabolic   powers  are   unable   to   respond    to   the 
demands  of  such  types  of  climate. 

7.  What   suits  the   prescribe!'   will  not  always,   perhaps 
seldom,   suit  his  patient;   and,  further,  one  must  bear  in 
mind  that  of  all  therapeutic  measures  at  our  disposal  climate 
alone  is  uninterrupted  in  its  action. 

8.  We  cannot  prescribe  particular  climates,  like  drugs, 
for   special   diseases.     Health   resorts   must   be   chosen   on 
scientific  and  rational  grounds;  empiracy  is  out  of  place 
and  dangerous. 

9.  The  type  of  medical  man  available  locally  is  of  very 
great  importance,  and  there  is  much  to  be  raised  in  objection 
to  the  foreigner. 

10.  When  a  British  health  resort,  therefore,  is  likely  to 
fulfil  all  the  ordinary  requirements  of  any  special  case,  it 
is  better  to  have  the  comforts  and  familiar  conditions  of 
oui1  own  country  rather  than  subject  the  patient  to  a  long 
Continental  journey  and  the  more  or  less  general  incon- 
veniences of  a  foreign  country. 

11.  The  average  amount  of  bright  sunshine,  the  relative 
humidity,  the  equability  of  temperature  and  pressure,  the 
rainfall  and  prevailing  winds,  must  all  be  taken  together 
in  estimating  the  therapeutic  value  of  a  climate,  and  110 
single   element    should  be   allowed  to  acquire  a   place   of 
disproportionate  importance. 

The  climate,  of  the  British  Isles  (lat.  50  to  60  N.)  belongs 
to  the  moderate  or  insular  type,,  which  is  mainly  dependent 
upon  the  presence,  the  temperature,  and  the  motion  of  the 


260        MANUAL  OF  PHYSIO-THERAPEUTICS 

sea  which  washes  our  shores.  The  chief  feature  of  the 
climate  is  the  absence  of  the  actual  extremes  of  heat  and 
cold.  Indeed,  the  British  climate  is  relatively  equable, 
owing  to  the  humidity  of  the  south-west  winds  which  are 
so  prevalent.  Our  summers  are  cool  and  moist;  our  rain- 
fall, lowest  in  April  and  highest  in  November  as  a  rule, 
though  considerable,  is  not  such  that  it  can  be  regarded 
as  a  serious  defect.  Our  southern  resorts  are  comparatively 
cool  in  summer  and  warm  in  winter;  our  mean  maximum 
temperature  is  reached  in  July  or  August,  and  the  mean 
minimum  in  December  or  January,  which  latter  is  often 
the  most  stormy  month  of  the  year. 

Our  inland  resorts  are  warmest  in  summer  and  coldest 
in  winter,  and  the  relative  humidity  is,  as  a  rule,  highest 
at  inland  stations  and  lowest  on  the  sea-coast,  which  is 
also  less  cloudy  on  the  whole  than  inland  districts.  During 
spring,  autumn,  and  winter  there  is  more  cloudiness,  which 
entails  sunlessness,  in  the  south-west  districts,  while  in 
the  summer  the  least  cloudy  areas  are  to  be  found  in  the 
southern  districts  and  coast-line.  The  prevailing  winds 
are  south  and  south-west,  but  winds  from  the  north-east 
are  most  prevalent  in  April,  May,  and  June,  the  last  month 
being  usually  the  driest.  In  Great  Britain  the  greatest 
differences  from  local  climates  arise  from  differences  in  the 
rainfall  and  the  direction  of  rain-bearing  winds  in  their 
relation  to  the  physical  configuration  of  the  surface.  This 
latter  is  undoubtedly  the  key  to  the  distribution  of  the 
rainfall  in  the  British  Isles.  As  regards  the  influence  of 
soil  on  the  rainfall  and  our  climate,  we  find  heavier  rain- 
falls in  the  upland  and  mountain  districts,  while  the  general 
geological  structure  and  contour  of  the  land  surface  have 
a  local  influence  on  temperature. 

The  chief  geological  formations  which  have  an  indirect 
influence  on  climate  are  roughly  the  dry  pebble  beds,  the 
sands  and  sandstones,  the  cold,  damp  clay,  and  shaly  soils, 
and  the  porous  limestones.  It  must  not  be  forgotten,  also, 
that  while  the  soil  influences  climate,  the  latter  produces 
certain  marked  effects  on  the  rock  formation  and  superficial 
soil,  as  well  as  on  the  configuration  of  the  lind  generally. 

Whatever  climate  we  select,   it  has  to  be  remembered 


CLIMATIC  TREATMENT  261 

that  there  is  no  perfect  climate,  and  that  no  health  resorts 
can  claim  the  monopoly  of  cure  of  disease  in  any  form. 
Few  climates  are  suitable  all  the  year  round  for  the  diseases 
most  likely  to  benefit  by  their  influence. 

Weber  laid  down  a  principle,  which  is  probably  very 
sound,  that  a  climate  with  constant  moderate  variations 
in  its  principal  factors  is  the  best  for  the  maintenance  of 
health,  and  such  is  the  climate  of  the  British  Isles,  often 
rainy  and  windy,  but  for  all  that  healthy  and  tonic. 

A  brief  survey  may  be  made  of  the  diseases  in  which 
climate  is  an  important  contributory  factor. 

In  cases  of  albuminuria  (functional  and  nephritic)  moun- 
tain or  moorland  air  has  a  favourable  effect,  and  districts 
like  Hindhead,  Crowborough,  Ilkley,  Moffat,  and  Church 
Stretton,  occur  to  us.  In  cases  of  chronic  parenchymatous 
nephritis,  as  well  as  early  granular  kidney,  we  may  find  it 
best  to  send  the  patient  away  for  the  winter  to  Northern 
Africa,  the  Canaries,  or  West  Indies.  If  this  is  either 
unnecessary  or  unpractical,  we  should  consider  Ventnor, 
Sidmouth,  Falmouth,  Penzance,  Tenby,  West  Kirby, 
Worthing,  or  Folkestone,  in  this  country,  for  winter,  while 
in  summer  Malvern,  Matlock,  Buxton,  and  Llanwrtyd  Wells, 
are  suitable. 

In  primary  anaemia  and  chlorosis,  in  addition  to  rest  and 
medicinal  treatment,  as  well  as  hygienic  and  dietetic 
measures,  benefit  will  usually  be  derived  from  residence  in 
summer  at  some  inland  hilly  resort  of  moderate  altitude 
(Braemar,  Buxton,  Church  Stretton,  Harrogate,  Llan- 
drindod  Wells,  Matlock,  or  Trefriw  Wells,  with  its  chalyb- 
eate springs) :  while  certain  seaside  resorts,  such  as  Brighton, 
Broadstairs,  Cromer,  and  Eastbourne  or  New  Quay,  are 
also  of  value,  more  especially  in  summer,  while  in  winter 
Bexhill,  Budleigh  Salterton,  Ventnor,  and  Salcombe, 
are  to  be  preferred.  Of  foreign  resorts,  Montreux,  Vevey, 
or  Glion  in  Switzerland,  and  Arcachon,  Biarritz,  or  Grasse 
in  France,  are  advised. 

In  hyperpyesis  or  the  involutionary  form  of  arterio- 
sclerosis, Clifford  Allbutt  advises  a  mild  equable  climate, 
such  as  Leamington,  Worthing,  Sidmouth,  Lyme  Regis, 
Torquay,  and  Falmouth. 


262        MANUAL  OF  PHYSIO-THERAPEUTICS 

On  the  other  hand,  where  there  is  extensive  and  advanced 
arteriosclerosis  with  associated  troubles,  such  as  asthma 
and  chronic  myocarditis,  places  such  as  Hastings,  St. 
Leonards,  Bexhill,  Worthing,  Bournemouth,  Sidmouth, 
and  Falmouth,  are  best  suited.  Asthma,  whether  of 
neurotic,  bronchial,  cardiac,  or  renal  origin  is  benefited, 
as  a  rule,  by  a  comparatively  low  or  moderate  altitude. 
It  is  difficult  to  say  what  exactly  will  suit  an  individual 
asthmatic,  as  they  differ  so  greatly,  and  some  do  well  in 
large  towns.  Many  find  the  Hampstead  region  an  Elys- 
ium, while  others,  again,  are  never  so  well  as  when  in 
Paris.  As  a  broad  rule,  both  in  summer  and  winter  there 
is  much  to  be  said  for  the  Speyside  district— Grantown- 
on-Spey  and  Nairn;  also  for  Hindhead  (800  feet  up)  and 
Haslemere  or  Malvern,  where  a  great  variety  of  altitudes 
is  available.  Of  seaside  places,  Broadstairs,  Worthing, 
Newquay,  Sidmouth,  Ventnor,  Paignton,  and  Torquay, 
are  best  suited.  For  chronic  winter  cough  and  bronchial 
catarrh  and  the  "  nervous  cough  "  associated  with  neur- 
asthenic conditions  one  of  the  following  resorts  will  answer : 
Bexhill,  Church  Stretton,  Folkestone,  or  Malvern.  Of 
inland  spas,  Bath,  Cheltenham,  and  Leamington,  suit 
chronic  bronchitics  in  winter ;  while  on  the  coast  such  places 
as  Bournemouth,  Sidmouth,  Broadstairs,  Worthing,  Tor- 
quay, Falmouth,  and  Tenby,  are  advised  as  regards  the 
South :  while  in  the  North  Rothesay,  Grange-over-Sands, 
and  Llandudno,  are  best  suited.  If  the  patient's  tastes 
are  for  foreign  resorts  and  his  purse  allow,  there  are  various 
suitable  spots  on  the  French  or  Italian  Riviera,  such  as  Pau, 
Hyeres,  and  Cimiez;  Mustapha  in  Algiers;  Taormina  in 
Sicily;  Assuan  in  Egypt;  Arcachoii  in  South- West  France; 
or  the  Canary  Islands — these  are  all  suitable,  and  the  selec- 
tion of  any  one  must  be  largely  a  matter  of  individual  taste. 

For  diabetics  and  milder  forms  of  alimentary  glycosuria 
such  places  as  Leamington,  Cheltenham,  Bath,  Clifton, 
or  West  Kirby  (on  the  Dee),  are  suitable  ;  while  abroad  they 
resort  with  benefit  to  Contrexeville,  La  Bourboule,  Marien- 
bad,  and  Vichy. 

Dyspepsia  is  such  a  hydra-headed  affection  both  as 
regards  causation  and  symptoms  that  it  is  difficult  to  give 


CLIMATIC  TREATMENT  263 

any  broad  statement  as  to  health  resorts.  Where  there 
is  gastric  catarrh,  however,  benefit  is  derived  from  the 
mineral-water  treatment,  the  dietetic  regimen,  and  physical 
exercise  obtained  at  places  like  Harrogate,  Llandrindod, 
Bridge  of  Allan,  and  Strathpeffer. 

The  fine  air  of  Folkestone,  Bexhill,  or  St.  Leonards  in 
winter  does  good  to  atonic  dyspepsia  associated  with  brain 
fag  and  overwork,  physical  or  mental.  Such  cases  come 
under  the  heading  "gastric  neurasthenia."  In  summer 
they  benefit  from  places  like  Cromer,  Hunstanton,  Holy 
Isle,  Westgate-on-Sea,  Peterhead,  or  Stonehaven  as  regards 
seaside  resorts;  Peebles,  Malvern,  Church  Stretton,  Crow- 
borough,  and  Hindhead,  Buxton,  Braemar,  or  Ilkley. 

All  the  above  resorts  are  well  suited  to  convalescence 
after  acute  illness  or  operation,  patients  gaining  weight 
and  taking  their  food  with  gusto  as  a  rule.  The  only  point 
to  bear  in  mind  is  the  season  of  the  year,  some  of  the  higher 
resorts,  such  as  Buxton  and  Peebles,  being  snow-bound  in 
winter. 

Patients  troubled  with  chronic  disease  of  the  middle  and 
internal  ear,  particularly  those  with  tinnitus,  are  best 
suited  by  a  dry,  bracing  inland  air  at  a  good  altitude.  In- 
creased humidity,  such  as  is  usually  experienced  at  the  sea- 
coast,  on  the  other  hand,  aggravates  this  distressing  trouble 
in  many  instances.  A  prolonged  sojourn  in  the  Surrey 
hills  or  highlands  of  Hampshire  or  at  Crowborough  is 
advisable. 

Chronic  eczema  and  various  other  skin  affections  are 
helped  by  visits  to  such  spas  as  Buxton,  Harrogate,  Llan- 
drindod, and  Strathpeffer,  climate  and  waters,  with  proper 
regimen,  all  tending  to  a  cure. 

Gout  and  chronic  fibrositis  of  all  types  similarly  benefit 
most  by  the  combined  climate  and  balneary  treatment, 
such  resorts  as  Buxton,  Bath,  Leamington,  Harrogate. 
Cheltenham,  Llaiidrindod,  and  Strathpeffer,  being  advised. 
On  the  Continent  Aix  and  Vichy,  Vittel,  Bad  Gastein, 
Royat,  and  Wiesbaden,  are  much  in  vogue,  but  it  is  ques- 
tionable if  they  have  more  to  offer  than  our  larger  British 
spas  either  in  climate,  baths,  or  skilled  physicians  of  long 
experience  in  this  class  of  disease. 


264        MANUAL  OF  PHYSIO-THERAPEUTICS 

Chronic  headaches  of  an  intractable  kind  are  often 
beneficially  affected  by  a  change  of  climate,  and  a  visit 
to  one  of  the  moderately  bracing  upland  districts,  such 
as  Church  Stretton,  Hindhead,  Crowborough,  Chagford, 
Peebles,  or  Moffat,  is  advised. 

Cases  of  insomnia  are  favourably  influenced  by  such 
resorts  as  Matlock,  Peebles,  Moffat,  Malvern,  Hindhead, 
and  Church  Stretton,  inland,  or  at  coast  resorts  such  as 
Bexhill,  Bournemouth,  Hastings,  Torquay,  Sidmouth, 
Nairn,  and  North  Berwick. 

The  climatic  factor  in  pulmonary  tuberculosis  has  been 
so  far  dealt  with  under  Sanatoria,  but  we  may  devote  a 
few  further  remarks  to  it  here.  There  are  four  main  types 
of  climate  to  consider : 

1.  Forest  and  woodland  country,  with  a  moderate  eleva- 
tion of  150  to  1,500  feet.     Probably  most  of  our  British 
sanatoria  come  under  this  head,  with  greater  or  less  prox- 
imity to  the  sea-coast.     The  advantages  to  be  mentioned 
are  purity  of  the  air,  the  pleasant  pine-wood  atmosphere 
(not  to    be   overvalued),  freedom  from  dust,  and  shelter 
afforded  by  the  trees.     Given  a  well-conducted  sanatorium, 
no  patient  can  want  more. 

2.  The  sea-coast  has  the  advantage  of  pure  and  often 
bracing  air,  moist,  with  a  more  steady  temperature  than 
on  the  hills  and  a  large  amount  of  sunshine.     There  is  a 
sedative  effect  on  nervous  patients,  but  some  subjects  get 
bilious  easily.     Land  and  sea  breezes  have  to  be  borne  in 
mind,  which  may  be  boisterous  and  trying  to  feeble  patients. 
One  may  mention  in  this  connection  Bournemouth,   the 
Norfolk  coast,  Sidmouth,  Newcastle,  Co.  Down,  and  Grange- 
over-Sands  (Meathop),  and  abroad  the  French  and  Italian 
Riviera,    Biarritz,    Arcachon,    Canary    Islands,    and   West 
Indies. 

Sea  voyages  come  under  the  same  heading,  but  here 
much  care  is  needed.  As  Sir  Douglas  Powell  said  to  a 
patient  once  on  the  suggestion :  "  Do  you  want  to  be 
sea-sick  ?"  This  has  to  be  remembered,  along  with  the 
fact  that,  though  the  deck  atmosphere  is  good,  that  of  the 
cabin  is  bad,  and  the  patient  may  have  to  spend  a  lot  of 
time  there.  Speaking  from  experience,  the  writer's  im- 


CLIMATIC  TREATMENT  265 

pression  is  unfavourable;  haemoptysis  in  crossing  the  tropi- 
cal zone  is  common. 

3.  Desert  climates  with  a  maximum  of  heat,  sun,  and, 
dryness,  such  as  Luxor,  Biskra,  Assuan,  and  Heloaan 
suit  some  people  and  have  a  good  psychic  effect,  but  dust- 
storms  are  very  hurtful  and  occur  periodically.  A  visit 
is  a  pleasant  change  to  subchronic  cases  where  means 
have  not  to  be  considered. 

Heart  Disease. — In  chronic  compensated  cases,  in  addition 
to  such  therapeutic  factors  as  rest,  regulated  diet,  exercise, 
medicinal  treatment,  and  special  methods,  such  as  the  Nau- 
heim  baths  and  the  Oertel  terrain  cure,  the  consideration 
of  climate  will  arise.  Of  inland  resorts,  suitable  places  are 
Leamington,  Bridge  of  Allan,  Aboyne,  Ballater,  Lower 
Deeside,  Buxton,  Church  Stretton,  Llangennech  Wells 
(600  feet),  Matlock,  and  Peebles;  as  regards  coast  resorts, 
Rothesay,  Grange-over-Sands,  Southport,  Seaton,  Sidmouth, 
Falmouth,  and  Broadstairs,  suggest  themselves. 

Care  is  necessary  to  see  the  locality  possesses  an  adequate 
number  of  level  walks  and  of  gradually  sloping  walks, 
all  with  some  degree  of  shelter  from  the  prevailing  wind. 
Places  with  frequent,  quickly  rising  gales,  like  some  of  our 
coast  resorts,  are,  of  course,  unsuitable,  as  the  patient  may 
have  to  struggle  back  against  a  head  wind,  with  very  bad 
results. 

In  neuralgia  which  has  lasted  a  long  time  and  refused  to 
yield  to  drugs  change  of  air  may  do  much  good,  a  change 
from  the  East  Coast  to  an  inland  or  South  Coast  resort 
being  often  followed  by  good  results.  Buxton,  Leamington, 
Hastings,  or  Bournemouth,  can  be  tried;  or  Braemar, 
Blackpool,  or  St.  Anne's,  Hindhead,  or  Church  Stretton. 
The  same  applies  to  the  severe  neuralgic  pain  observed 
after  recovery  from  herpes  zoster. 

Neuralgia  or  cachexia  after  malaria  is  favourably  affected 
by  a  stay  at  such  places  as  Buxton,  Harrogate,  Matlock, 
Church  Stretton,  Peebles,  or  Trefriw  (where  the  waters  are 
distinctly  beneficial  for  associated  ansemia). 

In  neurasthenia  many  factors  have  to  be  taken  into 
account  in  advising  any  climatic  or  balneary  cure.  No  two 
neurasthenics  are  alike,  and  while  many  will  do  well  at  a 


266        MANUAL  OF  PHYSIO-THERAPEUTICS 

busy  spa  like  Harrogate,  where  there  is  much  life  and 
brightness,  others  will  vote  it,  as  they  have  in  my  own  ex- 
perience, "a  nasty,  vulgar,  overcrowded  place!"  If  the 
case  is  severe,  quieter  places  are  better,  for  a  start  at  least, 
such  as  Ilkley,  Malvern,  Hindhead,  Crowborough,  Moffat, 
or  Braemar;  while  of  seaside  resorts,  Cromer,  Folkestone, 
Broadstairs,  Hastings,  Felixstowe,  Newquay,  and  Hunstan- 
ton,  suggest  themselves.  Brighton,  along  with  Harrogate 
and  North  Berwick,  will  do  for  the  less  acute  cases.  On  the 
Continent,  the  best  resorts  for  such  cases  are  Arcachon, 
Grasse,  Chateau  d'CEx,  Montreux,  Pau,  San  Remo,  Divonne. 

In  the  treatment  of  obesity,  diet,  the  terrain  cure,  and 
baths  having  been  prescribed,  such  resorts  as  Harrogate, 
Leamington,  Malvern,  and  Church  Stretton  or  Peebles, 
are  suitable.  Before  the  war,  Carlsbad,  Marienbad,  and 
Homburg,  were  greatly  in  vogue,  especially  in  obese  persons 
with  some  glycosuria. 

Rheumatoid  disease  requires  special  consideration,  and  a 
bright,  sunny,  dry  climate  must  be  sought,  with  a  sand  or 
gravel  soil  and  efficient  subsoil  drainage.  Buxton,  Droitwich, 
Nantwich,  and  Harrogate,  are  only  suitable  for  such  patients 
in  summer;  if  they  can  stand  the  moister  air.  Hunstanton 
or  Broadstairs  can  be  tried ;  but  in  winter,  the  purse  permit- 
ting, Chateau  d'Estoril  (Portugal),  Seville,  Biskra,  Monte 
Carlo,  and  Assuan,  are  very  suitable,  and  often  help  a 
great  deal,  balneary  facilities  being  available  at  most  of 
them. 


SECTION  V 
ELECTRO-THERAPEUTICS 

CHAPTER  I 
GALVANO-FARADISM 

Historical  Summary. 

ELECTRO-THERAPEUTICS  date  back  to  a  legendary  age.  It  is 
recorded  that  centuries  ago  the  women  of  Africa  bathed 
their  sick  children  in  waters  frequented  by  the  electric  eel, 
or  torpedo  (Malapterurus  electricus) ;  while  Actius,  in  the 
year  500  B.C.  states  that  those  suffering  from  gout  or  con- 
vulsions found  great  relief  by  holding  a  magnet  in  the  hand, 
and  earlier  still  the  Romans  employed  electricity  in  the 
forms  then  available  in  the  treatment  of  disease.  Scri- 
bonius  Largus,  during  the  reign  of  Tiberius,  used  electricity 
in  the  treatment  of  gout.  Crookes  humorously  attributed 
the  death  of  Tullus  Hostilius,  who,  according  to  Roman 
mythology,  was  struck  dead  by  one  of  Jove's  thunder- 
bolts, to  accidental  contact  with  "a  live  wire." 

Pliny  and  Dioscorides  both  refer  to  the  remedial  power 
of  electricity.  The  history  of  electro-therapeutics  may  be 
divided  into  four  eras — (1)  The  era  of  franklinization ; 
(2)  the  era  of  galvanization;  (3)  the  era  of  faradization; 
(4)  the  era  of  radiology,  etc. 

1.  The  Era  of  Franklinization. — One  of  the  prominent 
advocates  of,  and  writers  on,  franklinic  electricity  as  a 
therapeutic  agent  was  John  Wesley,  the  divine.  At  a  time 
when  the  medical  faculty  were  inclined  to  despise  electricity 
and  underrate  its  value  (as,  unhappily,  many  doctors  are 
still  inclined),  Wesley  claimed  that  electricity  was  indicated 
in  a  wide  range  of  disorders;  and  with  the  list  of  ailments 
which  he  drew  up  as  suitable  for  electrical  treatment  the 
more  modern  physician  who  has  studied  electricity  will 

267 


268         MANUAL  OF  PHYSIO-THERAPEUTICS 

find  little  fault.     Quite  independently  of  Franklin,  Wesley 
suggested  the  use  of  lightning-conductors. 

2.  The  Era  Of   Galvanization.— This  was  commenced  by 
Galvani's  classical  experiment  on  the  frog  in  1786.     After 
his  results  were  made  public,  Volta  was  attracted  to  the 
field  of  electrical  experiment,  and  constructed  his  pile,  which 
from  the  year  1800  onwards  was  largely  employed  in  medical 
work,  and  marked  a  distinct  advance  in  technique. 

Unfortunately,  most  of  the  work  at  this  period  was  done 
by  laymen,  who  knew  little  or  nothing  of  physiology  or 
medicine.  "  Chemists,  physicists,  priests,  paupers,  monks, 
and  mountebanks,  were  the  leading  authorities  on  electro- 
therapeutics in  the  eighteenth  century.  ': 

Many  years  elapsed  before  electro-therapy  attained  suffi- 
cient precision  to  command  the  attention  of  men  of  science. 

3.  The  Era  of  Faradization. — Michael  Faraday's  discovery 
of  the  principle  of  electrical  induction  in  1831  may  be  said 
to  have  changed  the  whole  course  of  electro-therapeutics. 
In  the  following  year  the  first  practical  machine  on  this 
principle  was  made  by  Pixii,  and  used  by  Neef  of  Frankfort 
in    the    treatment    of    disease.      From    this    time    faradic 
electricity  became  extensively  employed  throughout  Europe. 
Until    1895   galvanism,    faradism,    and  perhaps   to   a   less 
extent    static    electricity,    were    the    forms    employed    in 
medicine.     The  apparatus  required  was  not  very  elaborate, 
and  the  amount  of  work  done  in  a  large  general  hospital 
was  often  scarcely  sufficient  to  justify  the  existence  of  a 
special  electrical  department. 

4.  The   X-ray    Period. — The    discovery    of    X   rays   by 
Professor  Roentgen  in  1895  undoubtedly  gave  an  enormous 
impetus  to  electrical  work,  and  led  to  the  establishment 
of  a  radiographic  and  electrical   department  in  all  large 
hospitals.     The  field  for  the  electro-therapeutist  expanded, 
and  electrical  treatment,  to  some  extent,  was  taken  out  of 
the  hands  of  the  "  medical  electrician,"  or  electrical  quack. 

Soon  after  this  remarkable  results  were  obtained  by 
d'Arsonval,  Elihu  Thomson,  and  Tesla,  by  the  use  of  "  high- 
frequency  "  currents,  which  rushed  into  fashion  and  acquired 
a  permanent  place  in  electro-therapeutics,  along  with  many 
other  devices. 


GALVANO-FARADISM  269 


Electrical  Units. 

The  Volt  is  the  practical  unit  of  electromotive  force,  and 
is  the  electrical  pressure  which,  if  steadily  applied  to  a 
conductor  whose  resistance  is  1  ohm,  will  produce  a  current 
of  1  ampere,  and  which  is  represented  by  0-6974  part  of  the 
electrical  pressure  between  the  poles  of  the  well-known 
Clark's  cell  when  at  15°  C. 

The  Ohm  is  the  practical  unit  of  resistance,  and  is  the 
resistance  offered  by  a  column  of  mercury  at  0°  C., 
144521  grammes  in  mass  of  constant  cross-sectional  area, 
and  of  length  106-3  centimetres. 

The  Ampere  is  the  practical  unit  of  current,  and  is  the 
constant  electrical  current  which,  when  passed  through  a 
particular  solution  of  silver  nitrate  in  water,  deposits  silver 
at  the  rate  of  0-001118  gramme  per  second. 

The  Watt  is  the  practical  unit  of  power,  and  is  the  rate  of 
doing  work  when  a  current  of  1  ampere  flows  between  two 
points  having  a  difference  of  potential  of  1  volt,  and  is  the 
product  of  amperes  into  volts. 

The  Coulomb  is  the  unit  of  quantity,  and  is  the  quantity 
of  electricity  that  flows  per  second  past  a  given  point  in  a 
conductor  which  is  carrying  a  current  of  1  ampere.  The 
more  practical  unit  is  the  Ampere  Hour,  equal  to  3,600 
coulombs. 

The  Farad  is  the  unit  of  capacity,  and  is  the  capacity  of 
a  condenser  which  would  require  a  charge  of  1  coulomb 
to  produce  a  difference  of  potential  of  1  volt  between  the 
two  conductors  forming  the  condenser.  The  practical  unit 
is  a  Microfarad. 

The  Henry  is  the  unit  of  inductance,  and  is  the  inductance 
in  a  circuit  when  the  current  is  changing  at  the  rate  of 
1  ampere  per  second,  producing  in  that  circuit  a  difference 
of  potential  of  1  volt. 

In  order  to  render  the  above  units  more  clear  to  those 
who  are  not  acquainted  with  electrical  nomenclature,  we 
might  compare  them  with  that  of  a  hydraulic  system, 
which  to  the  minds  of  many  is  more  palpable.  The  dynamo, 
which  we  will  describe  later,  may  be  considered  as  a  rotary 


270       MANUAL  OF  PHYSIO-THERAPEUTICS 

pump  pumping  electricity  instead  of  water,  in  which  case 
we  have  a  pump  (dynamo)  forcing  water  (current)  at  a 
certain  number  of  pounds  pressure  (volts),  as  indicated  by 
the  pressure  gauge  (voltmeter),  to  overcome  the  friction 
(resistance)  of  pipes  (wire)  in  order  that  the  water  (current) 
may  flow  at  the  rate  of  so  many  gallons  (amperes)  per 
minute,  as  recorded  by  the  water-meter  (ammeter).  The 
larger  the  pipe  (wires),  the  more  water  (current)  can  be 
carried,  and  the  less  will  be  the  friction  (resistance). 
Obviously  the  pipe  (wire)  might  be  so  small  that  the  friction 
(resistance)  would  absorb  a  very  large  proportion  of  the 
power  of  the  pump  (dynamo),  having  but  little  remaining 
for  useful  effect.  If  the  pipe  (wire)  be  too  large,  it  will 
cost  too  much;  if  it  be  too  small,  the  loss  be  will  too  great. 
The  pipes  (wire)  require  valves  (switches)  to  regulate  and 
direct  the  water  (current),  with  fittings  (contacts)  sufficient 
to  convey  the  water  (current)  without  leak  (drop  of  poten- 
tial), and  safety  relief  valves  (fuses)  must  be  provided  to  pre- 
vent damage  from  overpressure  (voltage).  The  continuous 
current  is  similar  to  a  pump  drawing  water  from  a  reservoir 
and  forcing  water  through  a  system  of  pipes,  upon  which 
the  machines  may  be  connected  to  do  work  and  the  water 
returned  to  the  reservoir. 

The  alternating  current  is  similar  to  a  plunger  pump 
forcing  water  through  the  pipes  on  the  out-stroke  and 
drawing  it  back  again  on  the  in-stroke,  the  action  being 
repeated  with  great  rapidity  (periodicity). 

Current  derived  from  a  Battery. 

Wet  cells  have  now  fallen  into  almost  complete  desuetude 
if  we  exclude  accumulators  or  storage  batteries.  The  cell 
used  almost  universally  now  is  of  the  dry  type  of  Leclanche. 
We  must  confess  a  weakness  for  the  wet  bichromate  cell, 
for  a  small  Spamer  Battery,  the  elements  being  zinc  and 
carbon,  with  a  solution  made  up  of  1  ounce  of  bichromate 
of  potash,  1  ounce  of  bisulphate  of  mercury,  and  2  ounces 
of  strong  sulphuric  acid  in  a  pint  of  water,  as  the  excitant, 
but  there  is  always  the  risk  of  spilling  and  injuring  the 
battery.  With  a  dry  Leclanche  we  have  no  such  risks. 


GALVANO-FARADISM 


271 


There  is  no  creeping  of  salts  either,  as  with  a  wet  Leclanche, 
causing  erosion  of  the  wires  and  binding-screws.  They 
are  also  light,  which  is  of  great  importance  in  a  galvanic 
battery,  where  as  many  as  forty  cells  may  be  needed. 

Probably  the  best-known  types  just  now  are  the  Obach, 
made  by  Siemens,  and  the  Hellensen.  A  small  battery  is 
put  on  the  market  by  Davidson,  of  Great  Portland  Street, 
known  as  the  Da  von,  which  is  wonderfully  powerful  for  its 
small  size.  Another  of  the  same  type,  and  equally  good, 
is  that  of  Bruce,  Green  and  Co.,  Bloomsbury  Square,  W.C. 
This  is  oblong  in  shape ;  others  are  either  square  or  round 
—fitting  better  into  a  box,  of  course. 

The  main  disadvantage  in  these  cells  is,  they  cannot,  as 
a  rule,  be  recharged  when  they  are  exhausted,  but  Wilfred 
Harris  makes  a  practice  of  freshening  them  up  by  putting 


FIG.  133. — DRY  CELLS. 

them  on  to  the  main  like  an  accumulator;  the  effect  is,  of 
course,  only  temporary.  They  can  easily  be  sent  by  post, 
which  is  a  very  great  advantage. 

The  voltage  of  a  Leclanche  cell  is  1-5.  The  number 
required  in  a  battery  will  chiefly  depend  on  the  use  to 
which  it  is  to  be  put;  50  to  80  volts  will  be  required  for 
treatment  purposes. 

The  batteries  themselves  are  of  various  types,  from  the 
simplest,  as  far  as  possible  foolproof,  suitable  for  nurses' 
and  inexperienced  people's  use,  to  the  most  highly  finished 
and  equipped. 

The  Leclanche,  Cell. — The  wet  type  consists  of  a  square 
glass  jar  and  an  amalgamated  zinc  rod  in  an  electrolyte  of 
sal-ammoniac  solution,  and  a  depolarizer  consisting  of 
manganese  dioxide  contained  in  a  porous  pot.  In  the 


272         MANUAL  OF  PHYSIO-THERAPEUTICS 

centre  of  this  is  the  positive  pole,  a  carbon  rod.  The 
solution  consists  of  6  ounces  of  sal-ammoniac  dissolved  in 
a  pint  of  water. 

It  is  important  that  the  zinc  rod  be  amalgamated,  to 
prevent  local  currents,  which  cause  disintegration.  A  new 
one,  however,  can  be  procured  for  about  sixpence,  and 
should  always  be  obtained  if  the  old  one  is  at  all  corroded. 
Creeping  of  the  salts  can  be  prevented  so  far  by  brushing 
the  upper  inch  of  the  glass  jar  with  melted  paraffin  wax. 
If  it  happens  on  the  zinc  rod,  it  should  be  scraped  with  an 
old  knife. 

These  cells  are  not  portable,  but  they  are  easily  cleaned 
and  kept  in  order,  and  have  a  fairly  high  E.M.I1.  For 
medical  work,  however,  they  cannot  compare  with  dry 
cells,  some  of  which,  if  not  used,  only  lose  5  per  cent,  of 
efficiency  in  six  months.  In  these  the  negative  plate  is  a 
zinc  cylinder  with  a  wire  soldered  to  it;  it  is  also  the  con- 
tainer of  the  electrolyte.  The  sal-ammoniac  is  not  in  solu- 
tion, but  in  a  paste  made  up  with  glycerine,  water,  and 
plaster  of  Paris.  The  depolarizer  is  solid  also,  being  a 
mixture  of  manganese  dioxide,  sal-ammoniac,  and  glycerine ; 
this  encloses  the  carbon  positive  plate,  and  is  contained  in 
a  cotton  bag  inside  the  zinc  cylinder.  The  top  of  the  zinc 
container  is  then  closed  up  with  melted  pitch. 

These  cells  are  extraordinarily  reliable,  portable,  and 
inexpensive.  In  one  type  or  another,  made  by  different 
manufacturers,  they  have  entirely  displaced  wet  cells  in 
all  classes  of  electro-therapeutic  work,  if  we  exclude  the 
electric  cautery,  which  hardly  comes  within  the  province  of 
this  volume. 

Accumulators. 

Most  people  have  a  nodding  acquaintance  with  storage 
batteries  nowadays,  owing  to  their  frequent  employment 
in  connection  with  motor-cars  for  lighting  purposes,  etc. 
They  are  extremely  useful  where  the  main  supply  is  not 
immediately  available  on  the  spot,  but  where  charging 
facilities  are  within  a  reasonable  distance.  They  have, 
further,  a  very  low  resistance,  so  that  fairly  large  currents 
compared  with  dry  cells  can  be  obtained  on  ordinary  low 


GALVANO-FARADISM  273 

voltages,  which  renders  them  very  suitable  for  many 
medical  purposes,  such  as  operating  cautery  and  light  and 
portable  X-ray  apparatus.  The  voltage  per  cell,  when 
newly  charged,  is  approximately  2«5  volts,  but  very  soon 
falls  to  2  volts  after  discharge  begins,  and  there  remains 
till  practically  discharged,  which  should,  however,  never 
be  allowed  to  fall  below  1-8  volts  per  cell  before  being 
recharged,  otherwise  what  is  known  as  sulphation  of  the 
plates  will  take  place  in  a  very  short  space  of  time. 

In  the  ordinary  technical  sense  they  are  essentially 
secondary  batteries— that  is,  a  reversible  couple.  Such 
combinations  may  consist  of  a  soluble  cathode  and  an 
insoluble  anode  in  an  alkaline  or  acid  electrolyte,  such  as 
zinc-lead,  zinc-copper,  and  lead  peroxide  couples,  but  owing 
to  the  solubility  of  one  of  the  electrodes,  or  both,  renders 
this  type  of  cell  impracticable.  The  only  satisfactory  cells 
are  those  in  which  the  electrodes  are  insoluble,  thus  narrow- 
ing down  the  types  of  cells  to  those  of  the  lead  and  nickel 
potash  iron  type.  In  the  case  of  the  lead  type,  which  was 
invented  by  Plante  in  the  year  1860,  the  process  of  forma- 
tion of  the  electrodes  was  as  follows:  Two  sheets  of  lead 
were  immersed  in  a  cell  containing  dilute  sulphuric  acid, 
and  an  electric  current  passed  for  some  hours  through  same, 
during  which  time  the  metallic  lead  at  the  positive  pole 
became  converted  on  the  surface  into  peroxide  of  lead,  while 
that  at  the  negative  took  the  form  of  spongy  lead.  On  being 
disconnected  from  the  charging  source  and  the  two  poles 
connected  externally  by  a  wire,  it  was  found  that  a  current 
flowed  in  the  opposite  direction  to  that  in  which  the  charging 
current  passed — viz.,  from  the  spongy  lead  to  the  lead 
peroxide  externally — during  which  process  both  plates 
became  reduced  to  sulphate  of  lead,  in  which  condition 
all  current  ceased.  By  applying  same  to  the  source  of 
supply,  the  plates  were  again  converted  into  peroxide 
of  lead  at  the  positive  and  spongy  lead  at  the  nega- 
tive, and  in  this  condition  the  accumulator  is  what 
is  termed  charged.  When  fully  charged,  bubbles  of 
hydrogen  are  seen  to  leave  freely  at  the  negative  pole, 
and  a  red -brown  chocolate  colour  characteristic  of 
peroxide  of  lead  is  formed  on  the  positive  plates.  The 

18 


274        MANUAL  OF  PHYSIO-THERAPEUTICS 

accumulator  should  then  be  disconnected  from  the  charg- 
ing supply,  and  may  be  used  for  whatever  purpose  it 
is  desired.  As  the  capacity,  however,  of  an  accumulator 
is  dependent  first  upon  the  actual  area  in  contact  with  the 
acid,  which  in  the  case  of  the  original  Plante  cell  was  purely 
the  area  of  the  positive  electrode,  the  capacity  was  limited 
to  a  very  great  degree.  When,  however,  the  plates  were 
treated  with  nitric  acid,  it  was  found  that  the  capacity 
greatly  increased,  this  being  due  to  the  fact  that  a  very 
large  number  of  interstices  were  developed  in  the  surface 
of  the  lead  plate,  so  that  the  plate  surfaces  became  after  the 
style  of  a  sponge,  the  additional  area  being  obtained  by  the 
acid  permeating  into  the  plate  through  these  microscopically 
small  holes  on  the  surface,  which,  when  added  to  the  super- 
ficial area,  greatly  increased  the  total  active  surface  of  the 
plate.  Unfortunately,  however,  when  the  lead  plates  got 
into  this  condition  they  became  mechanically  weak,  as  the 
oxides  no  longer  have  the  mechanical  strength  of  the 
metallic  lead,  with  the  result  that  the  accumulator  plates 
rapidly  went  to  destruction.  Faure  at  a  later  date  intro- 
duced what  is  now  termed  the  "pasted  plate."  In  this 
the  active  material,  finally  taking  the  form  of  peroxide  of 
lead,  was  forced  into  a  lead  grid,  which  was  either  cast  or 
pressed,  in  the  form  of  red  oxide  of  lead,  or  in  a  further 
advanced  stage,  as  far  as  the  formation  of  the  plate  was 
concerned,  by  litharge  or  brown  sulphate  of  lead.  The 
plates  were  then  arranged  as  before  in  the  electrolyte  of 
dilute  sulphuric  acid,  and  the  current  passed  through  same 
as  before.  The  oxides  of  lead  now  became  converted  much 
more  rapidly  into  peroxide  of  lead  at  the  positive  pole  and 
spongy  lead  at  the  negative  pole;  and,  although  being  weak 
in  mechanical  strength,  was  supported  on  the  lead  grid, 
which  enters  very  little  into  the  operation  of  the  process. 
As  above  stated,  the  capacity  of  an  accumulator  depends 
upon  the  area  in  contact  with  the  acid,  but  is  also  affected 
by  the  discharge  current.  The  capacity  is  usually  calcu- 
lated in  terms  of  ampere  hours,  and  there  is  also  a  limit 
to  the  current  which  can  be  safely  taken  out  of  any  accumu- 
lator, and  is  reckoned  at  so  many  amperes  per  square  foot 
of  active  positive  surface,  and  is  roughly  in  the  neighbour- 


GALVANO-FARADISM  275 

hood  of  5  to  15  amperes  per  square  foot  of  plate,  according 
to  the  method  of  using  and  type  of  plate.  This  gives  what 
is  termed  the  maximum  discharge  current.  The  ampere- 
hour  capacity,  however,  is  roughly  the  average  discharge 
current  in  amperes  by  the  time  in  hours.  There  are  other 
ways  of  reading  the  capacity,  which,  however,  do  not  enter 
into  this  treatise. 

Regarding  the  other  form  of  couple — viz.,  the  nickel-iron 
storage  battery — which  is  associated  with  Edison  and 
Jungner,  has  for  its  positive  element  iron,  which  is  the 
negative  pole.  The  negative  element,  corresponding  to 
carbon  of  a  primary  cell  or  the  peroxide  of  lead  of  a  secondary 
cell,  as  previously  mentioned,  is  a  super  oxide  of  nickel, 
and  forms  the  positive  pole  of  the  battery.  The  electrolyte 
is  an  aqueous  solution  of  potassium  hydroxide.  The  voltage 
of  discharge  is  approximately  1«5,  but  varies  during  the 
discharge.  The  mean  voltage  of  full  discharge  is  approxi- 
mately 1-1  volts.  The  positive  and  negative  plates,  from 
a  mechanical  point  of  view,  are  alike,  and  so  far  are  com- 
posed of  a  comparatively  thin  sheet  of  steel  in  the  form  of 
a  grid,  and  the  grid  being  filled  up  with  the  active  material 
as  stated.  During  the  charging  the  current  deoxidizes  or 
reduces  the  iron  compound  of  the  positive  plate  to  spongy 
metallic  iron,  and  carries  the  oxygen  through  the  film  of  the 
electrolyte  to  the  nickel  compound,  converting  it  into 
hyperoxide  of  nickel,  which  is  a  higher  oxide  than  the 
peroxide.  This  gives  very  roughly  an  idea  of  its  action  as 
compared  with  the  lead  accumulator.  Its  advantages  over 
same  are  that  it  can  be  left  uncharged  without  deterioration, 
which  is  not  the  case  in  that  of  the  lead  accumulator, 
wherein  there  is  always  a  local  action  going  on. 

Management  of  Accumulators. — A  few  words  here  with 
reference  to  the  management  of  accumulators  would  not 
be  amiss,  as  it  is  an  important  point  to  always  have,  in  the 
case  of  medical  work,  your  accumulator  in  good  condition  and 
ready — as,  for  instance,  in  the  case  of  urgent  radiographic 
work — to  be  able  to  lift  same  to  operate  your  portable  X-ray 
apparatus.  This  can  only  be  done  by  keeping  the  following 
points  in  view: 

1.  Battery  should  be  kept  fully  charged,  never  allowing 


276        MANUAL  OF  PHYSIO-THERAPEUTICS 

it  to  become  fully  discharged;  that  is  to  say,  the  voltage 
per  cell  of  the  accumulator  should  never  be  allowed  to  fall 
as  low  as  1*8. 

2.  Never  allow  the  accumulator  to  stand  idle  for  any 
length  of  time  when  its  charge  is  low. 

3.  Charge  the  battery  up  until  what  is  known  as  the 
milky  stage  takes  place — that  is,  when  the  electrolyte  shows 
a  milky  appearance  due  to  the  ebullition  of  gas  at  both 
elements.     This  should  be  done,  properly  speaking,  at  least 
once  a  week.     In  a  house  where  electric  light  is  available 
this  can  easily  be  done  by  arranging  to  charge  it  by  suitable 
switches  through  a  radiator  or  lamps. 

4.  When  the  liquid,  or  electrolyte,  becomes  low  due  to 
evaporation,  and  which  should  have  a  specific  gravity  of 
1-7  to  1-75  when  charged,  and  never  allowed  to  fall  below 
1-2,  dilute  acid  should  be  added  with  a  specific  gravity  of 
1-8  until  the  electrolyte  covers  the  tops  of  the  plates. 

5.  It  is  important  to  test  the  voltage  per  cell,  and  not, 
as  many  do,  simply  take  the  total  voltage  of  the  accumulator. 
By  the  former  method  a  defective  or  not  fully  charged  cell  is 
rendered  obvious,  and  is  caught  in  time  to  have  it  put  into 
good  condition.     If  the  cells  must  stand  idle  for  any  length 
of  time,  they  ought  to  be  fully  charged,  and  if  possible 
given  a  very  short  charge  once  a  fortnight. 

NOTE. — When  mixing  acid,  do  not  add  water  to  acid 
but  acid  to  water  slowly,  and  allow  to  cool  before  putting 
it  into  cells. 

6.  Lastly,  see  that  the  proper  polarity  of  the  supply  is 
connected  to  the  cells  when  charging. 

Fig.  134  is  a  simple  type  of  what  is  known  as  a  nurse's 
or  patient's  battery.  The  cells  are  arranged  in  series — 
that  is,  the  positive  pole  of  the  first  cell  is  attached  to  the 
negative  of  the  second,  and  so  on,  until  all  the  cells  are 
included,  which  arrangement  gives  a  maximum  voltage, 
depending  on  the  number.  Thus,  ten  cells  yield  15  volts. 

Small  holes  are  made  in  the  front  of  the  case,  through 
which  metal  plugs  pass,  the  one  on  the  right  connecting 
with  the  positive,  and  that  on  the  left  with  the  negative 
pole.  One  of  the  cords  has  a  forked  end,  and  with  a  metallic 
plug  attached  to  each ;  this  is  used  for  increasing  or  diminish- 


GALVANO-FARADISM 


277 


ing  the  number  of  cells  in  the  circuit — two  at  a  time — so 
as  to  vary  the  strength  of  the  current.  The  chief  drawback 
to  this  type  of  battery  is  that  the  plugs  are  pulled  or  drop 
out  when  the  battery  is  in  use  sometimes,  and  the  patients 
get  a  bit  of  a  shock,  which  may  upset  nervous  patients. 

The  battery  can  be  locked  by  the  maker,  and  need  not 
be  opened  until  exhausted  or  returned  from  hire. 

A  convenient  size  of  battery  is  twenty-four  cells,  yielding 
36  volts.  The  cells  are  usually  4  inches  deep  by  1^  inches 
across,  and  a  battery  of  the  above  strength  will  weigh  about 
20  pounds.  The  cells  cost  about  2s.  6d.  at  present. 


FIG.  134. — XURSE'S  OR  PATIENT'S  BATTERY. 

For  a  medical  man  a  more  elaborate  type  of  battery  is 
desirable,  and  we  add  various  items,  such  as  a  cell  collector, 
commutator,  and  galvanometer.  Further,  we  may  wish 
to  make  it  a  combined  battery,  galvanic  and  faradic,  which 
involves  the  addition  of  a  small  sledge  coil.  Or  it  may  be 
preferable  to  have  a  small  Spamer  battery  as  an  aid. 

Current  Collectors. — These  are  used  to  increase  or  diminish 
the  number  of  cells  in  circuit,  thus  changing  the  E.M.F. 
and  regulating  the  strength  of  the  current.  They  must  be 
constructed  so  that  the  current  is  never  interrupted  while 
the  number  of  cells  is  being  changed,  as  this  causes  dis- 
agreeable shocks.  Further,  the  cells  must  be  put  into  the 


278        MANUAL  OF  PHYSIO-THERAPEUTICS 

circuit  one  by  one,  not  five  by  five,  as  this  will  again  cause 
shocks. 

Crank  Collectors  are  most  frequently  used.  A  number 
of  pegs,  equal  to  the  number  of  cells  in  the  battery,  are 
arranged  in  a  circle,  so  that  a  crank  can  be  brought  in 
contact  with  every  one  of  them  (Fig.  137).  The  cells  are 
then  connected  in  series  with  each  other,  and  connected 
with  these  pegs;  a  wire  leads  from  the  first  zinc  to  the 
negative  terminal,  another  wire  from  the  carbon  of  the 
first  cell  to  peg  1,  another  wire  from  the  carbon  of  the 
second  cell  to  peg  2,  etc.,  and  one  wire  leads  from  the  crank 
to  the  positive  terminal.  By  turning  the  crank  the  number 
of  cells  connected  with  the  terminals  can  thus  be  con- 
veniently increased  or  diminished.  In  order  to  avoid  inter- 


«»^  fes  iw^  y  »» 

FIG.  135. — CRANK  RIGHTLY         FIG.  136. — CRANK  WRONGLY 
PLACED.  PLACED. 

rupting  the  current,  the  pegs  are  so  arranged  that  the  crank 
touches  the  next  peg  before  having  quite  left  the  former  one. 

As  long,  however,  as  the  crank  touches  two  pegs — for 
instance,  pegs  5  and  6  (Fig.  137) — at  the  same  time,  the 
sixth  cell  is  short-circuited,  for  the  current  can  pass  from 
the  zinc  of  cell  0,  whicli  is  connected  with  the  carbon  of 
cell  5,  on  to  peg  5,  through  the  crank  of  peg  C,  and  from 
thence  back  to  the  carbon  of  cell  6,  without  finding  on  its 
way  any  resistance  worth  mentioning.  If  this  state  of 
affairs  lasts  but  a  very  short  time  it  causes  no  damage,  but 
if  it  continue,  the  short-circuited  cell  will  be  exhausted. 
It  is  therefore  important  with  all  crank  collectors  to  let 
the  crank  rest  as  in  Fig.  135,  and  not  as  in  Fig.  136,  where 
it  is  in  contact  with  two  cells  at  once. 

The  number  next  to  the  peg  on  whicli  the  crank  rests 


GALVANO-FARADISM 


279 


shows  the  number  of  cells  in  action.  This  kind  of  collector 
is  convenient,  but  it  has  one  drawback,  especially  if  used 
with  batteries  containing  a  large  number  of  cells— viz.,  that 
by  being  put  in  the  circuit  the  first  cells  of  the  batteries 
are  exhausted  more  quickly  than  the  last  ones. 

Double  Collector. — This  is  designed  to  obviate  the  above 
difficulty,  and  has  two  cranks,  which  are  placed  on  the 
same  axis,  but  are  insulated  from  one  another;  the  zinc  of 
the  first  cell  is  not  connected  with  a  terminal,  but  with  an 
additional  peg,  0.  One  crank  is  connected  with  the  positive 


FIG.  137. — DOUBLE  CRAXK  COLLECTOR. 

and  the  other  with  the  negative  terminal.  By  these  two 
cranks  any  batch  of  cells  may  be  inserted,  and  the  whole 
battery  used  up  evenly.  An  index  fitted  to  one  of  the 
cranks  points  to  a  division,  thus  showing  the  number  of 
cells  in  action. 

Finally,  each  single  cell  can  be  connected  with  a  galvano- 
meter and  tested,  so  that  damaged  or  exhausted  cells  may 
be  detected  without  trouble.  The  double  collector  is  thus 
a  great  convenience  in  testing  a  battery,  and  is  certainly 
the  best  collector  known  at  the  present  time. 


280        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  Medical  Battery. — The  above  is  a  fairly  common  type 
of  battery  suitable  for  a  doctor.  The  cells — from  twenty- 
four  to  forty-eight — are  arranged  in  a  suitable  box  of  oak 
or  mahogany,  coupled  in  series,  with  double-current  col- 
lector, commutator,  and  galvanometer.  It  is  a  continuous- 
current  battery  as  opposed  to  what  is  called  a  combined 
battery,  which  includes  ah  induction  coil.  The  fittings  are 
usually  fastened  to  a  sheet  of  vulcanite  or  of  wood  similar 
to  that  forming  the  box.  An  explanatory  word  may  be 


FIG.  138. — COMBINED  BATTERY  WITH  SINGLE  COLLECTOR. 

needed  about  cells  being  coupled  in  series.  In  this  way 
we  get  the  maximum  E.M.F.  with  a  small  amperage.  The 
negative  of  the  first  cell  is  joined  to  the  positive  of  the 
next,  and  so  on.  The  unconnected  zinc  and  carbon  form 
the  two  poles. 

As  we  know,  the  voltage  of  the  average  Leclanche  cell 
is  1-5  if  in  good  order.  If  a  number  are  connected  in  series, 
then  the  voltage  is  the  sum  of  the  voltage  of  the  separate 
cells.  We  have  a  large  internal  resistance  proportional  to 


GALVANO-FARADISM 


281 


the  number  of  cells  in  the  series,  but  are  able  to  overcome 
the  large  external  resistance  which  the  human  body  always 
affords;  therefore  for  electro-therapeutic  purposes  we  always 
have  cells  coupled  in  series. 

If  we  couple  cells  in  parallel — that  is,  connecting  all  the 
positives  and  all  the  negatives  together — the  internal 
resistance  is  inversely  proportionate  to  the  number  of  cells: 
we  have  a  low  voltage,  but  a  high  amperage  or  heavy 
current.  Practically  the  only  case  in  which  we  use  this 
arrangement  is  for  electro-cautery,  and  even  then  the 
individual  cells  should  be  of  large  capacity  and  of  equal 
voltage,  otherwise  currents  will  circulate  between  the  cells 
and  destroy  them. 


Electrodes. 

The  various  instrument  makers  see  to  it  that  there  is 
every  shape  and  variety  of  these  on  the  market.  They  are 
of  two  main  types — the  handled  electrodes  and  the  plate 


FIG.  139. — BUTTON  AND  EOLLER  ELECTRODES  ;  AND  MAKE  AND 
BREAK  HANDLE. 

variety  of  various  sizes.  Handles  of  oak  or  mahogany  are 
fitted,  and  at  the  base  is  a  hole  with  a  retaining  screw, 
through  which  the  wire  at  the  end  of  the  conducting  cord 


282        MANUAL  OF  PHYSIO-THERAPEUTICS 


is  attached.     Various   sizes   of   button   electrodes   can  be 
screwed  on  up  to  1|  inches  or  2  inches  square. 

The  active  surface  of  the  metal  of  the  electrode  is  covered 
with  chamois  leather,  which  must  be  of  even  thickness  and 
free  from  holes.  In  place  of  the  plate  a  roller  end  is  some- 


FIG.  140. — INDIFFERENT  ELECTRODES. 

times  provided,  which  is  of  special  use  in  the  labile  method 
and  electrical  massage.  Sometimes  a  means  of  making  and 
breaking  the  current  is  added  to  the  handle,  but  it  is  prc- 


FIG.  141. — CHAIN  MAIL  ELECTRODES. 

ferable  to  effect  this  at  the  battery  or  on  the  switchboard  by 
means  of  a  commutator. 

Plate  electrodes  are  made  of  zinc  or  white  metal  cut  into 
various  sizes  and  shapes,  Avith  a  retaining  screw  preferably 


GALVANO-FARADISM  283 

at  one  extremity,  to  which  the  connecting  cord  is  fastened. 
This  should  not  be  put  in  the  middle  of  the  surface,  as  if 
the  patient  has  to  lie  on  the  electrode  it  becomes  very 
uncomfortable  after  a  while.  Chain  mail  electrodes  have 
been  used  for  ionization,  but  are  not  to  be  specially  recom- 
mended, as  they  are  apt  to  break  up  easily. 

Considerable  care  is  needful  as  regards  the  connecting 
cords.  Those  sold  with  most  of  the  cheaper  batteries  are 
so  flimsy  as  to  be  almost  useless.  The  tinsel  thread  very 
soon  breaks,  and  gives  rise  to  shocks  and  much  waste  of 
time  investigating  why  the  current  is  not  passing  properly. 

One  of  the  best  ways  of  making  satisfactory  connecting 
cords  is  to  utilize  ordinary  electric  bell  wire  which  is  covered 
with  rubber  and  a  layer  of  waxed  thread.  Suitable  lengths 
of  this  can  be  cut,  and  the  special  pin  or  wire  end  for  attach- 


FIG.  142. — WRISTLET  ELECTRODE  FOR  ELECTRIC  MASSAGE. 

ment  to  the  binding  crew  can  be  dispensed  with.  They 
do  not  always  fit  the  hole,  and  a  break  in  the  circuit  some- 
times occurs  just  where  the  pin  joins  the  cord.  This  trouble 
is  avoided  if  we  use  the  bell  wire  and  simply  scrape  the 
insulating  covering  off  the  end  of  the  cord  with  a  blunt 
knife,  leaving  about  an  inch  of  the  copper  centre  bare. 
This  can  be  passed  through  the  hole  of  the  electrode,  or 
if  the  screw  fastener  is  of  the  telegraph  type,  as  sometimes 
happens,  it  can  then  be  looped  around  it.  Details  such  as 
these  may  seem  trivial,  but  save  an  immense  amount  of 
time  in  practical  work  if  attended  to  carefully. 

Tests  for  Polarity.— All  properly  constructed  electric 
batteries  and  switchboards  are  marked  by  the  maker  so  as 
to  indicate  the  sign  of  the  electrode,  one  binding  screw 
being  negative  and  the  other  positive.  It  may  be  desirable, 
however,  from  time  to  time  to  test  the  poles,  and  this  is 


284        MANUAL  OF  PHYSIO-THERAPEUTICS 

an  easy  matter.  This  may  be  done  by  connecting  two 
wires  to  the  binding  screws  of  the  battery  or  board,  and 
dipping  them  into  a  tumbler  of  water  with  the  ends  |  inch 
apart.  The  negative  end  gives  off  a  lot  of  bubbles,  due 
to  the  liberation  of  hydrogen.  Alternatively  pole-finding 
paper  may  be  used,  and  when  applied  moistened  the  negative 
pole  turns  red.  The  ordinary  litmus-paper  used  for  urine 
testing  may  be  used  also,  blue  litmus  turning  pink  at  the 
positive  pole.  A  battery  never  changes  as  regards  its 


FIG.   143. — NEAT  TYPE  OF  COMBINED  BATTERY  WITH  DOUBLE 

COLLECTOR. 

polarity  unless  by  accident  during  recharging  or  repairing, 
but  with  switchboards  on  town  supplies  it  is  different,  and 
the  mere  turning  around  of  the  wall  plug  is  all  that  is 
necessary  to  give  rise  to  reversal. 

Effects  of  Galvanism  on  the  Skin. — The  action  of  the  two 
poles  varies.  If  we  take  two  electrodes  about  1  inch  in 
diameter,  and,  placing  them  on  the  skin  about  2  inches 
apart,  pass  a  current  of  2  to  3  milliamperes,  it  is  noticed 
that  the  sensation  at  the  negative  pole  is  more  marked  and 


GALVANO-FARADISM  285 

may  even  be  painful.  If  the  current  is  kept  up  for  an  hour 
or  more,  we  may  even  cause  an  ulcer,  especially  if  there  is 
any  unevenness  in  the  surface  of  the  electrode.  Bare 
metals  should  never  be  allowed  to  touch  the  skin;  they 
must  be  covered  with  chamois  leather  of  uniform  thickness. 
If  the  leather  gets  worn  at  any  point  and  the  metal  works 
its  way  through,  a  painful  sore,  very  slow  to  heal,  is  caused. 
This  is  due  to  the  whole  of  the  current  for  the  time  becoming 
focussed  on  the  spot  covered  by  bare  metal,  giving  rise  to 
a  very  high  current  density  at  this  spot.  We  have  known 
this  to  occur  through  the  attendant's  carelessness,  and  the 
patient  having  the  idea  that  he  or  she  should  be  prepared 
to  submit  to  a  reasonable  amount  of  discomfort.  Indeed, 
the  patient's  sensations  are  not  really  a  sufficient  guide  to 
what  is  occurring.  When  a  current  of  3  milliamperes  or 
more  is  passed  for  five  minutes  or  over,  a  periodic  inspection 
is  desirable  to  see  the  electrodes  are  moist  and  that  they  are 
evenly  applied,  and  note  taken  if  there  is  any  suggestion 
of  redness  and  blistering.  This  is  always  most  likely  to  take 
place  at  the  negative  electrode. 

Greater  safety  is  secured  by  placing  a  layer  of  lint  or 
cotton- wool  below  the  electrode,  though  it  is  already  covered 
with  wash-leather  or  flannel.  The  leather  should  be  moistened 
with  hot  water,  and  the  addition  of  baking  soda  materially 
increases  the  conduction. 

A  fall  in  the  amount  of  current  passing,  as  shown  by 
the  galvanometer,  is  a  sign  of  commencing  electrolysis 
of  the  skin,  especially  if  accompanied  by  a  burning 
sensation  of  the  skin  under  the  pad.  Fresh  water  must 
be  applied  to  the  electrodes  so  as  to  improve  the  con- 
duction. 

The  amount  of  sensation  always  largely  depends  on  the 
area  of  the  electrode,  and  this  brings  us  to  the  subject  of 
the  density  of  the  current  at  any  point. 

Density  of  the  Current. — The  size  of  the  electrodes  is  of 
considerable  importance.  The  larger  the  electrode,  the 
smaller  the  resistance  of  the  human  body.  Electrodes  of 
10  square  inches  surface  will  pass  through  the  body  twice 
the  current  that  can  be  conveyed  by  5  square  inches  under 
otherwise  equal  conditions.  This  leads  us  to  the  density 


286        MANUAL  OF  PHYSIO -THERAPEUTICS 

of  the  current,  or,  in  other  words,  the  proportion  of  the 
strength  of  current  to  the  sectional  area  of  the  conductor. 
If,  for  instance,  with  electrodes  of  3  square  inches  surface 
20  milliamperes  are  passing  through  the  body,  the  current 
is  three  times  as  dense  as  if  electrodes  of  9  square  inches 
and  the  same  strength  of  current  were  used.  In  other 
words,  in  the  first  case  each  square  inch  of  the  places  of 
application  receives  6-6  milliamperes,  whereas  in  the  second 
case  only  2-2  milliamperes  are  received  by  the  same  area. 
The  physiological  and  chemical  effects  would  in  the  first 
case  be  three  times  as  strong  at  and  near  the  point  to  which 
we  apply  the  electrode  as  in  the  second  case.  Statements 
that  such  and  such  results  have  been  obtained  with  so  many 
milliamperes  are  therefore  incomplete  unless  the  area  of  the 
electrodes  used  and  the  time  of  application,  are  mentioned 
as  well.  On  entering  the  body  the  current  divides  itself 
into  numerous  loops  and  branches,  and  follows  the  best 
conducting  parts  till  it  reaches  the  other  electrode.  The 
density  is  greatest  where  the  two  electrodes  touch  the  body; 
it  is  a  little  less  near  the  straight  line  connecting  the  two 
electrodes,  and  smallest  in  those  parts  of  the  body  which 
are  most  distant  from  the  electrodes;  but  experiment  shows 
that  even  those  parts  are  reached  by  some  small  part  of 
the  current. 

Failure  of  a  Battery  to  Work. — When  a  battery  does  not 
work  the  problem  facing  one  at  once  is,  Where  does  the 
fault  lie :  is  it  in  the  cells,  the  terminals,  cords,  or  handles  ? 
Five  times  out  of  six  it  will  be  in  the  connecting  cords.  In 
all  batteries  of  any  strength,  when  the  two  bare  ends  of 
connecting  cords  are  momentarily  brought  into  contact 
and  separated  again,  a  spark  will  be  seen.  If  this  is  not 
seen,  then  test  each  cord  by  fastening  it  to  a  terminal  and 
touching  the  other  terminal  with  the  end.  If  still  no  spark 
be  seen,  touch  the  first  peg  with  one  end  of  the  cord,  and 
with  the  other  end  touch  the  last  peg  of  the  collector.  If 
still  there  be  no  spark  visible,  test  the  cells  in  groups  of 
five,  either  with  the  pegs  on  the  current  collector,  or  by 
touching  the  terminals.  In  this  way  faulty  cells  or  weak 
groups  of  cells  may  be  singled  out.  Difficulty  may  arise 
from  screws  011  the  cells  working  loose  in  transit,  and  a 


GALVANO-FARADISM  287 

general  overlook  now  and  then  is  always  a  precaution 
against  trouble  of  this  character. 

Much  trouble  was  caused  in  the  old  days  by  using  wet 
cells,  which  occasionally  cracked,  the  contained  corrosive 
fluid  escaping.  With  dry  cells,  all  separate,  any  individual 
weak  element  may  be  removed  and  replaced  from  spare 
stock.  Reference  to  the  maker  is  thus  avoided  and  time 
saved. 

A  galvanometer  may  be  called  into  requisition  and  cells 
tested  one  by  one.  If  the  battery  is  a  small  one,  not  more 
than  ten  cells,  one  can  detect  the  absence  of  current  by 
touching  the  tongue  with  the  terminals.  If  the  cell  be 
working,  a  peculiar  taste  is  at  once  noticed. 

Faults  rarely  occur  between  the  cells  and  current-col- 
lectors, as  the  wires  are  well  protected  and  the  invisible 
connections  soldered.  At  times  the  pegs  of  the  collector 
and  the  current  reverser  become  oxidized,  and  need  a  clean 
up  with  fine  emery  paper.  Dust  between  the  studs  of  the 
collector  requires  removal  with  a  fine  hair  brush. 

The  screws  holding  the  cranks  of  the  current  collector 
in  their  place  may  need  tightening  at  times.  Care  must 
be  taken  never  to  put  cords  or  handles  or  wet  electrodes 
on  the  collector,  as  they  may  cause  a  short  circuit, 
destroying  the  cells. 

Faradism. 

Faradic  currents  are  those  produced  from  induction  coils, 
and  are  probably  the  most  frequently  employed  of  all 
electro-medical  methods,  especially  by  the  only  partially 
trained,  as  their  manipulation  is  simple  and  comparatively 
free  from  risk;  owing  to  the  sharp  contraction  of  muscles 
treated  also,  the  patient  feels  satisfied  that  he  is  getting 
"  value  for  his  money." 

The  main  use  of  currents  of  this  character  is  really  to 
excite  and  give  exercise  to  sluggish  or  feeble  muscles,  striped 
or  unstriped,  stimulating  them  through  their  nerves  of 
supply  and  so  increasing  their  nutrition. 

It  is  an  excellent  adjunct  to  massage,  and  makes  the 
treatment  more  interesting  to  patients  than  is  plain  massage. 
Some  physicians  have,  however,  a  very  poor  opinion  of  the 


288        MANUAL  OF  PHYSIO-THERAPEUTICS 

therapeutic  value  of  this  current.  A  well-known  neurologist 
once  informed  the  writer  he  looked  upon  it  as  little  more 
than  a  diagnostic  agent  for  investigating  reaction  of  de- 
generation, and  so  forth.  This  is  a  hard  saying.  But  it 
is  to  be  feared  that  the  busy  little  battery  of  the  Spamer 
type,  cheap  to  buy  and  easy  to  run,  does  lend  itself  materi- 
ally to  a  certain  amount  of  lay  quackery,  and  to  people 
"  trying  electricity  "  where  there  is  no  chance  of  a  good 
result. 

Speaking  from  personal  experience,  there  is  no  doubt 
but  that  the  faradic  current  is  of  therapeutic  worth. 

The  actual  current  may  be  derived  from  a  small  coil 
with  one  or  more  dry  Leclanche  cells,  or  from  a  switch- 
board, or  from  one  of  the  universal  apparatus,  such  as  the 
multostat.  There  is  much  in  favour  of  a  sledge  coil  worked 
from  a  dry-cell  battery  or  from  a  wall  plug  on  the  town 
supply.  This  is  really  an  ordinary  Du  Bois  Raymond  coil, 
the  primary  coil  having  200  to  300  turns  of  wire,  and  the 
secondary- many  more.  The  primary  wire  is  usually  insu- 
lated copper  wire,  No.  22  B.W.G.  The  E.M.F.  of  the 
primary  coil  is  between  5  and  30  volts,  according  to  whether 
the  core  is  pushed  home  or  not.  Indeed,  on  this  core 
depends  very  much  our  means  of  varying  the  current 
strength,  as  the  faradimeter  is  rather  a  laboratory  than 
clinical  apparatus. 

The  Induction  Coil. 

The  modern  induction  coil  or  sledge  coil,  of  which  the 
above  is  a  scheme,  is  a  modification  of  the  Du  Bois  Raymond 
coil.  In  Fig.  144  D  represents  the  battery  or  the  main; 
a  the  wire  from  the  positive  pole,  and  g  that  from  the 
negative;  $  is  a  brass  upright;  F  the  spring  supporting  the 
armature  or  the  Neef  (or  Wagner)  hammer;  b  the  contact 
screw;  c  the  wire  forming  the  primary  helix  (xx)  containing 
the  soft  iron  core;  KK  the  secondary  winding  or  helix, 
with  board  (pp)  on  which  it  can  be  moved ;  H  soft  iron  core 
magnetized  by  the  current  when  passing  around  it. 

When  the  current  in  this  is  closed,  the  horse-shoe  // 
becomes  magnetized  and  attracts  the  armature  or  Wagner 


GALVANO-FARADISM 


289 


hammer  e,  breaking  the  contact  with  the  screw  b  in  doing 
so.  The  current  is  then  broken,  and  the  horse-shoe  promptly 
becomes  demagnetized;  the  armature  e  being  liberated 
springs  back,  by  aid  of  the  spring  /,  to  its  original  position 
on  contact  screw  6,  thus  re- 
establishing the  current.  H 
becomes  remagnetized,  and  the 
whole  process  is  repeated 
quickly  ad  infinitum. 

We  obtain  the  faradic  cur- 
rent from  what  is  known  as 
an  induction  coil,  and  the 
principle  upon  which  it  oper- 
ates is  that  of  electro-magnetic 
induction.  The  principal  parts 
of  same  are  the  interrupter, 
the  primary  circuit,  and  the 
secondary  circuit.  In  Fig.  144 
will  be  found  an  illustration 
showing  the  general  arrange- 
ment of  the  various  parts  of 
a  modern  instrument,  such, 
for  example,  as  a  Du  Bois 
Raymond  coil.  In  same  D  re- 
presents the  battery  or  main 
supply,  A  the  wire  from  the 
positive  pole,  S  that  from  the 
negative  pole.  8  is  a  brass 
upright  supporting  F,  the  spring 
carrying  an  armature  of  soft 
iron,  e;  B  an  adjustable  screw 
with  a  platinum  contact  piece 
which  presses  against  a  corre- 
sponding platinum  piece  011 
the  spring  F ;  C  the  wire  form- 
ing the  primary  coil,  in  the  axis  of  which  is  a  core,  /,  of 
a  bundle  of  soft  iron  wires.  H  is  a  piece  of  soft  iron  in 
the  form  of  a  horse-shoe,  round  the  poles  of  which  is  wound 
a  coil  of  wire.  K  is  the  secondary  coil,  which  is  mounted 
on  a  base  permitting  to  be  slid  at  will  over  the  primary 

19 


290 


MANUAL  OF  PHYSIO -THERAPEUTICS 


coil.  L  is  a  switch  whereby  the  circuit  is  closed  when  it 
is  desired  to  operate  same.  On  closing  the  switch  L,  the 
current  flows  from  a  through  S  to  F ;  there  by  the  platinum 
contacts  to  contact  screw  6 ;  from  there  through  the  primary 
coil  C  to  horse-shoe  with  coil  H ;  finally  through  switch  L 
to  negative  pole  of  battery.  As  the  current  passes  through 
coil  H  of  horse-shoe,  the  soft  iron  is  converted  into  a  tem- 
porary magnet,  which  lasts  as  long  as  the  current  lasts, 
and  attracts  the  soft  iron  armature  e,  which  causes  the 
spring  F  to  leave  the  contact  screw  at  the  platinum  points, 


FIG.  145  —DIAGRAM  OF  NEEF'S  HAMMER  AND  INTERRUPTER. 

thus  breaking  the  electric  circuit  and  causing  the  horse-shoe 
to  lose  its  magnetism,  with  the  result  that  the  armature 
e  is  released  from  the  magnetic  grip  and  returned  by  spring  F 
to  its  original  position  in  contact  with  screw  b,  which  imme- 
diately gives  rise  to  a  similar  cycle  of  operation  by  again 
closing  the  circuit  and  exciting  the  horse-shoe  magnet, 
which  in  turn  again  attracts  the  armature  e,  and  so  on, 
The  number  of  times  this  cycle  is  repeated  per  minute 
depends  on  the  strength  of  the  current,  the  mass  of  the 
armature,  and  the  strength  of  the  spring  F  and  positior\ 
of  contact  screw  6,  and  is  known  as  the  number  of  inter-- 


G  ALVANO-FARADISM  2  91 

ruptions  of  the  primary  current  per  minute.  The  above 
description  refers  to  the  action  of  the  interrupter,  whose 
main  function  is  to  give  rise  to  a  variation  in  the 
strength  of  the  magnetic  field  enclosing  the  primary  coil, 
and  which  in  turn  can  also  be  made  to  enclose  more  or 
less  entirely  the  secondary  coil  by  sliding  same  over  the 
primary. 

At  the  present  time  there  are  many  different  forms  of 
interrupters,  but  the  foregoing  description  holds  good  for 
practically  all.     The  main  difference  lies  in  the  fact  that 
with  the  cheaper  coils  the  spring  F  with  this  armature  is 
sometimes  actuated  by  the  magnetism  forming  part  of  the 
primary   winding   of   the   coil.     This,   however,   has  many 
disadvantages,  and  among  them  a  very  limited  amount  of 
control  of  the  rate  of  interruption.     That  shown  in  Fig.  145 
is  a  very  good  type,  and  is,  as  a  rule,  attached  to  the  best 
types  of  coils.     The  contact  spring  in  this  case  is  replaced 
by  a  solid  brass  bar  which  carries  the  hammer,  and  is  pivoted 
on  a  fulcrum  with  a  helical  spring,  the  tension  of  which  can 
be  controlled  by  a   small  thumb-screw,    R.     The  electro- 
magnetic in  this  case  is  separate  and  made  up  as  described 
in  the  beginning  of  this  section.     In  addition  to  the  screw  R 
for  varying  the  tension,  there  is  a  small  screw,  J,  mounted 
on  the  lever  carrying  the  hammer,  its  function  being  to 
modify   the  growth   of  the   magnetic   field,   otherwise   the 
wave-form  of  the  make  and  break  induced  E.M.F.  in  the 
primary  and  secondary.     There  is  also  a  sliding  knob,  K, 
which  can  be   moved  up  and  down  an  aluminium  angle 
piece  which  is  attached  to  the  armature,  as  shown  in  the 
illustration,  when  it  is  desired  to  make  the  rate  of  inter- 
ruption very  slow.     In  other  words,  it  simply  adds  to  the 
total   mass    of    the    armature,    and   varies   the   oscillating 
period  of  same.     A  very  fine  adjustment,  also,  is  obtained 
by  varying  the  position  of  K  on  the  upright  part.     By  this 
means  interruptions  can  be  made  as  low  as  sixty  per  minute, 
and   even  less.      If  the  natural  period   of  the  oscillating 
system  is  small,  and  likewise  that  of  the  time-rise  of  the 
current,  then  the  rate  of  interruption  will  be  very  high,  and 
under  these  conditions  anesthesia  can  even  be  produced. 
This,  however,  requires,  generally  speaking,  a  special  form 


292 


MANUAL  OF  PHYSIO-THERAPEUTICS 


of  interrupter  whereby  this  object  is  attained,  and  will  be 
described  later. 

Origin  of  Induced  Currents. — If  the  two  ends  of  a  wire 
are  connected  with  a  sensitive  galvanometer,  and  a  magnet 
brought  near  the  wire,  the  needle  of  the  galvanometer 
declines  so  long  as  the  magnet  is  approaching,  and  returns 
to  zero  if  the  interval  between  wire  and  magnet  is  allowed 
to  remain  constant. 

If  the  magnet  be  withdrawn,  the  needle  declines  again, 
but  in  the  opposite  direction.  If  in  the  neighbourhood  of 
the  closed  conductor  a  second  wire  is  drawn  parallel  to  the 
first,  and  this  second  wire  is  connected  with  a  galvanic 
cell,  the  needle  deflects  the  moment  the  circuit  is  closed, 
although  there  is  no  connection  whatever  between  the  two 
wires;  but  it  returns  to  zero  immediately  afterwards,  and 
remains  there,  although  the  galvanic  current  continues  to 
circulate  in  the  second  wire.  If  we  diminish  or  interrupt 


FIG.  146. — DIAGRAM  ILLUSTRATIVE  OF  INDUCED  CURRENTS. 

the  current,  the  needle  deflects  again,  but  in  the  opposite 
direction,  thus  showing  that  the  approaching  and  with- 
drawing of  the  magnet — or  the  making  and  breaking  of  the 
current  in  the  conductor  close  by — induces  currents  in  the 
closed  circuit,  which  are,  however,  of  very  short  duration 
and  pass  in  the  opposite  direction. 

The  currents  induced  by  a  closing  current  then  pass  in 
the  opposite  direction  to  the  inducing  current,  and  those 
induced  by  breaking  the  first  inducing  current  pass  in  the 
same  direction  as  it  does.  If,  therefore,  we  make  and  break 
the  inducing  current  very  often  consecutively,  we  induce 
each  time  a  momentary  current  in  another  conductor;  but 
the  direction  of  these  induced  currents  keeps  changing, 
and  they  are  therefore  called  alternating  currents  in  contra- 
distinction to  those  which  keep  their  polarity. 

Self-induction— Extra  Currents. — The  wire  through  which 
the  inducing  current  passes  is  called  the  primary  wire,  and 


GALVANO-FAR  ADISM  2  93 

the  wire  in  which  currents  are  induced  is  called  the  secon- 
dary; the  induced  current  is  called  the  secondary  current. 
For  various  reasons  the  primary  and  secondary  wires  are 
not  drawn  in  a  straight  line,  but  are  wound  in  spirals 
on  cylinders  of  wood,  paper,  etc.,  which  are  made  of  such 
sizes  that  the  primary  coil  can  be  pushed  into  the  secondary 
coil.  In  a  spiral,  each  turn  of  the  wire  is  parallel  with  the 
previous  and  following  turns  of  the  same  spiral;  and  a 
current  which  passes  through  a  turn  of  the  spiral  must 
therefore  have  an  inducing  influence  on  the  other  turns 
close  by.  This  effect  of  the  different  turns  of  the  same 
spiral  on  each  other  is  called  self-induction,  and  the  current 
thus  induced  is  called  the  extra  current.  If  the  current  is 
made,  the  extra  ciuTent,  too,  has  an  opposite  direction  to 
the  inducing  current,  and  thereby  retards  and  weakens  it, 
and,  consequently,  the  secondary  also;  but  if  the  inducing 
current  is  interrupted,  the  extra  current  flows  in  the  same 
direction  as  the  inducing  current,  and  thereby  increases 
the  latter  considerably,  and  the  secondary  current  as  well. 
The  shocks  induced  by  making  and  breaking  the  inducing 
current  are,  therefore,  of  very  unequal  strength;  those 
made  by  breaking  the  inducing  current  predominate  very 
much,  and  the  signs  -]-  and  -  ,  which  are  marked  on  the 
terminals  of  the  better  induction  coils,  are  intended  to  show 
the  direction  of  the  currents  induced  by  breaking  the 
inducing  current.  The  signs  would  have  no  meaning  if 
the  currents  resulting  from  making  and  breaking  the 
inducing  current  had  an  equal  strength,  as  they  follow  one 
another  in  opposite  directions. 

Primary  Currents. — If  we  connect  one  or  two  galvanic 
cells  with  a  Wagner's  hammer,  which  is  provided  with  a 
small  electro-magnet  only,  and  connect  the  cells  by  two 
further  wires  with  two  electrodes  which  we  hold  in  our 
hands,  we  shall  not  feel  the  making  or  breaking  of  the 
current.  But  if  the  current  has  to  pass  a  primary  coil 
with  several  hundred  turns  of  wire  besides  the  Wagner's 
hammer,  each  breaking  of  the  current  gives  us  a  decided 
shock,  the  strength  of  which,  amongst  other  things,  depends 
upon  the  number  of  turns  of  the  coil,  and  varies  with 
the  extra  current.  This  is  the  primary  current  which  we 


294        MANUAL  OF  PHYSIO-THERAPEUTICS 

obtain  from  medical  induction  apparatus;  it  is  an  inter- 
mittent galvanic  current,  very  considerably  increased  by 
the  extra  current,  but  it  is  not  alternating.  The  inducing 
effect  of  a  current  is  considerably  increased  by  letting  it 
act  simultaneously  with  a  magnet,  and  this  can  be  arranged 
easily  if  the  primary  wire  is  wound  round  an  iron  core,  or, 
better,  if  it  is  wound  round  a  cylinder  into  which  an  iron 
core  can  be  pushed.  It  is,  howrever,  preferable  that  the 
core  should  consist  of  a  bundle  of  soft  iron  wires,  as  these 
take  and  lose  magnetism  much  more  quickly  than  solid  iron. 


FIG.  147. — SCHEME  OF  G-ALVANO-FARADIC  BATTERY,  WITH  SLEDGE 
COIL,  DOUBLE  COLLECTOR,  CURRENT  EEVERSER,  GALVANOMETER, 
AND  CELL  CONNECTIONS  SHOWN. 


The  Electro-motive  Force  of  the  induced  current  depends— 
(1)  On  the  number  of  turns  of  wire  which  a  coil  has:  the 
more  turns  the  higher  the  E.M.F.;  (2)  on  the  strength  of 
the  inducing  currents:  the  stronger  the  latter,  the  higher 
the  E.M.F.  of  the  induced  currents;  (3)  on  the  presence  or 
absence  of  soft  iron  core:  its  presence  increases  the  E.M.F. 
of  the  induced  current  very  materially ;  (4)  on  the  suddenness 
of  the  break  of  the  inducing  current.  Ultimately  the 
E.M.F.  of  the  secondary  current  depends  on  the  distance 
between  the  secondary  and  primary  coils;  the  closer 


GALVANO-FARADISM  295 

they    are    together,    the    higher    is    the    E.M.F.,   and   vice 
versa. 

Strength  of  the  Induced  Current. — This  is  dependent, 
again,  on  Ohm's  law  that  the  current  is  equal  to  the  E.M.F. 
divided  by  the  resistance.  If  the  induced  current  be 
70  volts  and  the  resistance  of  the  secondary  coil  610  ohms, 
and  that  of  the  patient  2,300,  then  the  strength  of  the 
current  would  be : 

-=0-024  ampere,  or  24  milliamperes. 


610+2,300 

The  strength  of  the  induced  current  cannot  be  measured 
by  an  ordinary  galvanometer,  since  the  secondary  currents 
are  alternating,  and  would  be  at  one  moment  causing  a 
deflection  of  the  needle  to  the  right  and  at  another  to  the 
left, 

Some  galvanometers  which  are  made  without  a  permanent 
magnet  may  be  used,  but  the  chief  obstacle  is  that  the 
currents  are  intermittent,  and  since  each  impulse  lasts  a 
very  short  time  only,  the  galvanometer  remains  without 
a  current  until  the  second  impulse  occurs. 

The  indication  given  by  the  galvanometer  will  vary 
directly  with  the  number  of  interruptions,  showing  much 
more  current  with  thirty  breaks  than  with  five  breaks  per 
second,  although  the  actual  current  strength  remains  con- 
stant. The  only  possible  way  to  measure  currents  of 
far  a  die  coils  is  by  their  E.M.F.  (see  below). 

The  chemical  action  of  faradic  currents  is  but  small, 
chiefly  on  account  of  their  short  duration,  but  also  because 
they  are  alternating,  so  that  each  following  impulse  in  the 
secondary  partially  neutralizes  its  predecessor.  This  in 
no  way  detracts  from  the  mechanical  effect  on  nerve  and 
muscle,  which  is  intense.  Muscles  contract  sharply  when 
the  contact  is  made  with  the  electrode,  and  even  more 
sharply  when  it  is  broken. 

Differences  in  the  Effects  produced  by  Primary  and 
Secondary  Currents. — The  physiological  effects  produced 
by  the  use  of  secondary  currents  depend  on  the  strength 
of  the  inducing  current,  the  quality  of  iron  in  the  core  of 


296       MANUAL  OF  PHYSIO-THERAPEUTICS 

the  primary,  the  number  of  interruptions  per  second,  and 
the  ratio  of  the  number  of  turns  of  the  primary  to  those 
of  the  secondary. 

If  all  conditions  are  the  same,  with  the  exception  of  the 
ratio  of  the  primary  to  the  turns  of  the  secondary,  then 
the  physiological  effects  produced  vary  with  the  voltage 
and  the  current ;  the  greater  the  number  of  turns,  the  higher 
the  voltage  produced.  A  great  number  of  turns  causes 
prickly  pain  locally,  but  not  strong  muscular  contractions. 
If  we  decrease  the  number  of  turns  and  reduce  the  resistance 
by  increasing  the  sectional  area  of  the  wire,  the  local  pain 
effect  diminishes  and  there  are  powerful  contractions  of 
the  muscles  to  be  observed.  These  latter  currents  are 
largely  used  for  treating  deeply  seated  organs,  the  former 
type  for  treating  nerves  and  other  parts  lying  near  the 
surface  of  the  skin. 

The  effects  produced  by  the  primary  current  are  similar 
to  those  produced  by  the  secondary  with  a  corresponding 
number  of  turns.  It  is  possible  to  regulate  the  current 
better  by  a  movable  secondary  of  equal  turns  to  the  primary 
than  by  moving  the  iron  core  out  or  in;  the  movable 
secondary  is  specially  recommended  in  electric  bath  treat- 
ment. 

Regulation  of  the  Primary  Currents. — The  E.M.F.  of  the 
primary  current  can  be  regulated  in  different  ways;  for 
instance,  by  inserting  a  larger  or  smaller  number  of  turns 
of  wire  by  means  of  a  crank,  etc.  The  simplest  and  almost 
only  practical  method,  however,  is  to  regulate  the  E.M.F. 
by  pushing  the  iron  core  in  and  out.  The  primary 
current  is  weakest  if  the  iron  core  is  drawn  out,  and  be- 
comes stronger  as  it  is  pushed  in.  Instead  of  drawing 
the  iron  core  out,  a  damper  in  the  shape  of  a  brass 
or  copper  tube  can  be  slipped  over  it  with  the  same 
effect.  If  the  iron  core  is  entirely  covered  with  the  tube 
its  inducing  power  ceases,  but  the  E.M.F.  increases  the 
more  the  brass  tube  is  withdrawn.  The  position  of  the 
secondary  coil  has  no  influence  on  the  strength  of  the 
primary  current. 

Regulation  of  the  Secondary  Current. — The  secondary 
coil  is  generally  constructed  with  a  large  number  of  turns 


GALVANO-FARADISM 


297 


of  wire — about  2,000  to  6,000 — for  in  most  cases  it  is  desired 
to  obtain  a  high  E.M.F.  The  wire  used  is  generally  thin 
copper,  about  No.  36  B.W.G.  The  resistance  of  the 
secondary  coil  varies  under  these  circumstances  between 
100  and  900  ohms,  and  the  E.M.F.  between  10  and  200  volts. 
The  strength  of  the  secondary  current  can  be  regulated 
in  different  ways.  If  the  apparatus  has  a  small  primary 
coil,  it  is  sufficient  for  all  purposes  of  treatment  to  regulate 
the  strength  of  the  secondary  current  by  merely  pushing 
the  iron  core  in  and  out,  for  a  current  which  is  hardly  to  be 
felt  when  the  iron  core  is  drawn  out  can  be  increased  quite 
gradually  to  painful  strength  by  pushing  it  home.  The 
more  complete  coils,  however,  are  so  arranged  that  the 
distance  between  the  primary  and  secondary  coil  can  be 


m  I  I  I  I  M  111  Ml  II  IgsF 

T^'--^'-^--^^-^---^^^  - 


Fi<;.   148. — DIAGRAM  ILLUSTRATING  THE  REGULATION  OF  THE 
SECONDARY  CURRENT. 

easily  changed  (see  Fig.  148).  In  this  case  the  secondary 
coil  slides  on  a  sledge,  and  can  be  pushed  over  the  primary 
or  be  drawn  away  from  it.  an  arrangement  which  allows 
an  exceedingly  fine  regulation  of  the  current.  These  sledge 
coils,  which  were  first  suggested  by  Du  Bois  Raymond,  are 
decidedly  preferable  to  any  others  for  diagnostic  and 
physiological  purposes.  The  strength  of  current  in  this 
apparatus  can  be  further  regulated  by  pushing  the  iron 
core  in  and  out  (Fig.  149).  The  secondary  current  might 
also  be  regulated  by  means  of  a  crank  which  inserts  more 
or  less  turns  of  wire,  but  this  does  not  allow  of  as  fine  gradua- 
tion as  the  moving  of  the  iron  core  or  the  coils;  or  it  might 
be  regulated  by  rheostats,  but  this  is  not  very  practicable, 


298        MANUAL  OF  PHYSIO-THERAPEUTICS 

and   is    seldom    employed,    as   high   resistances   would   be 
required. 
The  Regulation  and  Measurement  of  the  Current  Strength. 

— Some  means  of  regulating,  to  a  greater  or  less  degree,  the 
strength  of  the  current  is  necessary. 

The  following  are  the  methods  commonly  employed: 

1.  The  strength  of  the  magnetic  field  is  varied  by  the  use 

of  a  sliding  core,  as  shown  in  Fig.  149.     A  small  auxiliary 

electro-magnet  is  employed  to  work  the  interrupter.     The 

current  is  a  somewhat  irregular  one  of  low  frequency.     The 


FIG.  149. — Du  Bois  BAYMOND'S  COIL,  WITH  ADJUSTABLE  IN- 
TERRUPTER AND  SLIDING  CORE  FOR  REGULATING  CURRENT 
STRENGTH. 

interruptions  are  rather  unpleasant  to  the  patient,  and  such 
instruments  are  ill-adapted  for  delicate  electrical  testing. 

2.  A  movable  secondary  coil  is  used,  which  can  be  brought 
into  weaker  or  stronger  parts  of  the  magnetic  field  of  the 
instrument.     This  method  gives  a   wide  range  of  current 
strength,  but  is  only  suitable  for  regulating  the  secondary 
current. 

3.  The  iron  core  of  the  primary  coil  may  be  covered  by 
means  of  a  metal  tube  which  slides  over  it  and  shields  the 
coils  from  its  magnetic  action. 

4.  The  current  strength  may  be  varied  by  means  of  inter- 
posed resistance  in  the  exciting  or  secondary  circuit. 


GALVANO-FARADISM 


299 


5.  A  switch  may  be  used  which  brings  into  action  a 
greater  or  less  number  of  the  windings  of  the  secondary 
coil. 

The  Measurement  of  Faradic  Currents. — As  previously 
stated,  the  faradimeter  of  Sloan  is  rather  a  laboratory  toy 
than  a  therapeutic  aid.  Galvanometers  are  of  little  more 
use,  for  two  reasons.  Many  of  them  which  are  capable  of 
measuring  an  alternating  current,  such  as  the  "  hot  wire  " 
type  of  galvanometer,  are  not  sufficiently  sensitive  to 
measure  a  few  milliamperes  only.  But  more  important 
than  this  is  the  fact  that  galvanometers  cannot  be  used 


FIG.  150. — APPARATUS  FOR  FARADIZATION. 

unless  all  the  interrupters  of  the  coil  the  current  of  which 
is  to  be  measured  vibrate  at  a  uniform  and  fairly  rapid  rate. 

Since  a  galvanometer  will  register  less  if  there  be  only  five 
interruptions  per  second  than  if  there  are  twenty  or  more 
— current  being  constant — the  difficulty  is  plain. 

Various  workers  have  shown  that  currents  of  a  very  short 
duration  and  a  certain  E.M.F.  give  the  same  physiological 
effects,  whether  they  are  produced  by  an  induction  coil, 
a  galvanic  battery,  or  a  condenser  discharge.  A  coil  was 
therefore  constructed  in  which  the  scale  was  graduated  in 
volts;  the  readings  of  the  scale  are  correct  as  long  as  there 
is  a  primary  current  of  exactly  0-3  ampere.  Further 
condensers  were  constructed  of  one  microfarad  capacity, 
which  could  be  charged  from  a  battery  and  discharged 


300        MANUAL  OF  PHYSIO-THERAPEUTICS 

through  the  patient  in  rapid  succession  by  a  key  working 
like  the  interrupter  of  a  coil.  If  the  number  of  volts  used 
for  charging  the  condenser  is  known,  the  current  can  be 
measured,  and  the  results  compared,  just  as  the  number 
of  milliamperes  with  a  continuous  current. 

The  use  of  a  continuous  current  with  an  interrupter 
worked  by  an  electric  motor  has  been  suggested  for  test- 
ing the  reaction  of  muscles,  and  for  treatment  with  the 
interrupted  current.  The  interrupter  or  reverser  is  fixed 
on  the  axis  of  the  motor;  it  is  in  the  circuit  of  a  galvanic 
battery  (or  the  current  from  the  main),  and  a  milliampere- 
meter  is  also  in  the  circuit.  By  means  of  the  latter  the 
current  flowing  through  the  patient  can  be  measured  while 
the  interrupter  is  at  rest;  when  it  is  started,  the  galvano- 
meter will  indicate  less,  and  the  difference  between  the 
two  readings  can  be  used  to  find  out  the  duration  of  the 
current.  If  the  galvanometer  indicates,  for  instance,  one- 
fifth  of  its  former  reading,  it  shows  that  the  current  is 
closed  for  one-fifth  and  "off  "  for  four-fifths  of  the  time 
of  a  period  or  revolution.  The  proportion  between  the  time 
it  is  "on"  to  the  time  "off"  can  easily  be  varied  and 
adjusted  by  altering  the  position  of  one  of  the  two  brushes. 

It  has  been  proved  that  more  powerful  contractions  of 
muscles,  with  less  pain,  are  obtained  with  short  contacts 
and  long  intervals  with  no  current — i.e.,  if  the  brushes 
are  so  adjusted  that  the  time  during  which  the  current 
is  closed  is  only  about  one-tenth  of  that  during  which  the 
current  is  "off."  The  number  of  interruptions  per  minute 
can  be  adjusted  by  means  of  a  rheostat  controlling  the  speed 
of  the  motor,  and  can  be  read  off  a  speed-counter.  The 
E.M.F.  used  can  be  regulated  by  increasing  or  diminishing 
the  number  of  cells  or  amount  of  current  in  the  circuit. 

We  have  dealt  fully  with  the  whole  theory  of  induction 
and  the  coil  based  on  Faraday's  work,  without  which  it 
is  impossible  to  have  a  clear  grasp  of  the  method  of  working 
of  a  faradic  battery. 

Having  done  this,  we  can  now  treat  with  the  actual 
apparatus.  There  are  two  main  types  of  faradic  battery 
in  use:  first,  the  small  self-contained  and  portable  Spamer 
type,  costing  about  30s.,  with  a  dry  cell  or,  better,  two; 


GALVANO-FARADISM  301 

and  the  Lewis  Jones  sledge  coil  with  a  separate  battery. 
The  latter  is  best  operated  from  a  plug  in  a  lamp  socket 
on  the  direct  current  main,  and  is  very  handy  when  giving 
massage  in  a  ward  of  a  hospital  or  patient's  room.  It  is 
more  adapted  for  taking  from  house  to  house,  and  can  be 
conveniently  contained  in  an  ordinary  doctor's  or  nurse's 
hand-bag. 

From  the  main  we  may  use  as  an  intermediary  the 
galvanoset  with  a  faradic  attachment,  the  faradiset,  or  one 
of  the  various  types  of  switchboard  or  universal  apparatus. 

All  types  of  batteries  and  switchboards  are  provided 
either  with  separate  primary  and  secondary  terminals  or 
with  a  switch,  which  is  the  better  arrangement.  The  respec- 
tive uses  of  these  two  currents  have  been  dealt  with  above. 

Electrodes. — There  is  little  to  say  about  these  more  than 
has  been  said  under  galvanism.  They  are,  for  all  intents 
and  purposes,  identical.  The  roller  electrode  has  some 
advantage  if  general  faradization  be  called  for.  This  is 
used  much  as  is  general  massage,  and  the  whole  body 
brought  under  the  influence  of  the  faradic  current. 
Nerves  are  stimulated,  muscles  thrown  into  contraction, 
etc.  The  metabolism  is  improved  along  with  the  circula- 
tion and  general  body  nutrition.  A  weak  current  is  at 
first  employed,  or  the  patient  may  acquire  an  early  dislike 
to  the  treatment  difficult  to  remove. 

The  electrodes  are  referred  to  as  indifferent  and  active. 

The  indifferent  electrode  is  usually  a  large,  oblong,  flat 
plate  of  white  metal,  on  which  the  patient  lies,  care  being 
taken  that  contact  is  maintained,  the  sacrum  being  a  good 
region  to  apply  it. 

The  active  electrode  is  always  smaller,  and  usually  a 
disc  or  roller,  as  referred  to  previously. 

It  is  very  convenient  to  apply  the  current,  however, 
through  a  masseur's  hands,  the  operator  wearing  a  little 
wristlet  electrode  with  a  spring  which  grasps  his  wrist. 
Many  patients  prefer  this  method,  especially  those  who  are 
accustomed  to  massage. 

Failure  to  Work. — If  an  induction  coil  fails  to  work,  it 
should  be  first  seen  if  the  connection  with  the  main  is  faulty, 
if  the  fuse  has  burnt  out,  or  if  the  cell  element  is  exhausted 


302        MANUAL  OF  PHYSIO-THERAPEUTICS 

where  one  is  in  use.  If  the  source  of  supply  is  not  defective, 
then  the  interrupter  must  be  investigated.  This  is  the  most 
delicate  part  of  the  induction  coil,  and  therefore  care  is 
necessary  not  to  interfere  with  the  contact  screw  if  it  is  not 
strictly  necessary,  for  very  often  apparatus  which  were 
in  quite  good  order  have  been  spoiled  by  playing  with  this 
screw.  The  interrupter  does  not  always  start  of  its  own 
accord,  and  has  to  be  put  in  vibration  by  being  slightly 
touched  with  the  finger.  The  hammer  should  be  arranged 
so  that  its  distance  from  the  electro-magnet  is  about  tV  part 
of  an  inch,  and  the  platinum  point  of  the  contact  screw 
should  just  touch  it.  Those  apparatus  in  which  the  hammer 
is  fastened  to  a  rigid  bar,  as  in  all  sledge  coils,  are  less 
liable  to  get  out  of  order  and  to  require  readjustment  than 
coils  the  hammer  of  which  is  attached  to  a  watch-spring. 
The  interruptions  of  these  latter  apparatus  are  also  fre- 
quently less  regular.  If  an  interrupter  has  not  the  proper 
distance  from  the  electro-magnet,  it  has  to  be  carefully 
bent  till  it  keeps  the  correct  distance.  The  spark  on  the 
interrupter  attracts  dust,  and  the  little  platinum  sheet 
should  be  cleaned  occasionally  with  fine  emery  paper.  Oil 
should  on  no  account  be  allowed  on  the  interrupter. 

If  the  apparatus  still  fails,  although  cell  and  interrupter 
are  right,  see  whether  the  connecting  cords  are  in  order. 
To  try  an  apparatus  by  touching  the  terminals  or  the  con- 
necting cords  with  two  fingers  is  useless.  It  can  only  be 
tested  with  well-soaked  and  properly  connected  electrodes. 
The  coil  and  the  connections  are  very  well  protected,  and 
can  be  damaged  only  by  spilling  a  good  deal  of  acid;  the 
connections  become  oxidized  in  such  a  case,  or  the  wires 
may  even  be  eaten  through.  An  apparatus  damaged  in 
this  way  has  to  be  sent  back  to  the  manufacturer  for  repair. 

The  Electrical  Examination  of  the  Muscles  and  Nerves. 

By  this  procedure  in  neurology  the  physician  derives  the 
most  important  information  in  differentiating  between  an 
upper  and  lower  neuron  lesion,  and  in  estimating  the 
degree  of  degeneration  which  has  taken  place  either  in  the 
ueive  or  muscle  which  it  supplies. 


GALVANO-FARADISM  303 

We  require  at  least  what  is  called  a  combined  battery, 
or  preferably  a  galvanoset  or  switchboard  with  sledge  coil, 
and  further  use  two  conducting  wires  and  three  different 
electrodes — one  large,  about  6  by  4  inches,  a  medium  size 
round  one,  and  a  small  disc  about  1  inch  diameter.  The 
two  smaller  electrodes  have  handles;  some  people  work 
with  an  interrupting  handle,  but  it  is  better  to  work  with 
a  switch  or  commutator  on  the  board  for  turning  on  and 
off  the  current.  There  is  thus  less  chance  of  making  mistakes 
in  small  movements  occasioned  by  taking  the  electrode 
away  and  putting  it  back  again  on  the  part  being  examined. 

If  we  proceed  to  test  the  faradic  reaction  first,  the  large 
indifferent  electrode  is  placed  on  some  part,  such  as  the 
back  of  the  patient's  neck,  or  face  up  on  a  table  while  the 
patient  presses  his  hands  on  it.  The  small  electrode,  the 
effect  of  which  we  have  to  observe,  is  then  moved  over  the 
various  motor  points  of  the  muscles  to  be  tested.  Alter- 
natively, the  person  carrying  out  the  examination  may  put 
himself  into  the  circuit  by  holding  the  small  electrode  in 
his  hand,  or  by  means  of  a  wristlet,  and  then  touch  the 
various  points  with  his  finger,  previously  moistened. 

A  knowledge  of  the  motor  points  is  a  help,  but  not  essen- 
tial, as  charts  are  easily  obtainable,  and  much  may  be 
learned  of  the  condition  by  passing  the  small  electrode  or 
finger  up  and  down  the  muscles  more  or  less  at  random. 

The  motor  point  of  a  muscle  is  usually  near  the  point  of 
entry  of  the  nerve  into  the  muscle,  while  that  of  the  nerve 
is  near  its  most  superficial  part.  The  electrodes  and  skin 
should  be  always  thoroughly  moistened  with  warm  water, 
and  soaping  the  surface  of  the  electrode  which  is  moved 
about  is  of  service.  Salt  is  unnecessary,  and  eventually 
leads  to  corrosion. 

The  patient  should  be  placed  in  a  good  light,  where  both 
sides  of  the  body  can  be  observed  equally.  First  observe 
what  amount  of  current  is  needed  to  produce  a  contraction 
of  the  healthy  side,  and  then  test  the  side  suspected  of 
disease  with  the  same  amount.  See  if  there  is  any  con- 
traction, and  if  not  note  the  amount  of  current  required  to 
produce  one. 

The  faradic  contraction  of  a  muscle  can  be  only  obtained 


304       MANUAL  OF  PHYSIO -THERAPEUTICS 

through  the  nerve  of  supply,  whether  the  muscle  be  healthy 
or  the  reverse. 

If  the  nerve  is  damaged  or  diseased,  then  the  response 
will  be  proportionately  feeble,  or  there  may  be  a  total  loss 
of  faradic  reaction.  A  diminution  of  faradic  response 
indicates  some  disease  of  the  lower  motor  neuron. 

In  testing  with  galvanism,  we  have  to  estimate  both  the 
quantitative  and  the  qualitative  changes.  The  galvano- 
meter must  be  studied  to  note  the  minimal  amoimt  of  current 
required. 


N.  raillalia. 

M.  brachUl.  intern.     [ 
M.  supinator  long.      / 
M.  radial,  ext,  long. 


M.  triceps  (caput  »\t.) 
M.  triceps 
loaput  long.) 
M.  deltoideus 
ipost.  half). 

(N.  axillaris) 


M.  radial,  ext.  brev 
11.  exteus.  digit,  comniuuh 

M.  extens.  digit,  min 
M.  extens.  indicia 

M.  abduct,  pollic.  long. 
M.  exteus.  pollic.  brev.. 


M.  abduct,  digit,  min.  (N   ulnaris.) 


tlrn.  inteross.  dorsal.  I,  II,  III,  et  IV. 
(N.  ulnaris.) 

FIG.  151. — MOTOR  POINTS  OF  THE  EADIAL  NERVE  AND  THE 
MUSCLES  SUPPLIED  BY  IT:  DORSAL  SURFACE. 


As  regards  the  qualitative  changes  greater  care  is  needed. 
We  begin  with  the  cathode  placed  about  the  surface  of  the 
motor  point  we  are  investigating.  If  we  make  contact 
with  the  negative  pole,  we  have  the  kathodal  closing  con- 
traction. If  we  use  the  anode,  it  is  the  anodal  closing 
contraction,  or  A.C.C.  Normally  K.C.C.  is  greater  than 
A.C.C.,  and  A.O.C.  than  K.O.C.  In  various  nerve  diseases 
this  is  altered,  and  we  have  the  reverse  and  other  modifica- 
tions; these  we  call  polar  changes. 


GALVANO-FARADISM 


305 


M.  ton  tails 

Upper  branch  of  facial 

M.  corrug.  supercil. 

M.  or 


Region  of  central 

Re ffion  of  3rd  frontal 

of  Reil  (centre  for 
speech) 
M.  tc-roporalls 

I'jtper  branch  i 
in  front  of  t 

Facial  n.  (trunk) 

Middle  branch  of /anal 

M.  splenius 
M.sternocleicio- 

mastoideus 
SpiniU  accessory  n. 
M.  levator  anguli  scnpul- 
M.  trapezius 
Berviml  plexia 


(M.  pectoral.). 


FIG.  152. — MOTOR  POINTS  OF  FACE. 


M.  deltoideus  (ant.  half)  N.  axillaris. 
N.  rnuscuio-cutaneus. 
M.  biceps  brachii. 

M.  brach.  anticus. 


-bductor  p'jllic.  bre». 
[  opponens  pollicis. 
M.  flex.  poll.  brev. 
II.  abductor  poli 


M.  pronator  teres. 

M.  flex,  digitor.  commun 
M.  flex,  carpi  radial  i 
M.  flex,  digitu 
:  II.  flex 

(dig.  iud.  etniin.) 
M.  flex  poll. 


N.  uluaris. 


Mm.  luiril.ri- 
ilesIIIetlV. 
M.  opponens  digit  min. 
M.  flexor  digit,  mill. 
M.  abductor  digit,  mm. 
M.  i  almaris  brev 


M.  flexor  carpi  uluaris. 


N.  ulunris. 


FIG.   153. — MOTOR  POINTS  OF  THE  MEDIAN  AND  ULNAR  NERVES, 
WITH  THE  MUSCLES  SUPPLIED  BY  THEM. 

20 


306        MANUAL  OF  PHYSIO-THERAPEUTICS 


We  have  spoken  above  of  testing  electrodes  with  an 
interrupter  on  the  handle;  these  are  not  recommended. 
The  interrupter  is  liable  to  lose  its  insulating  properties, 
so  that  the  patient  gets  a  shock  when  least  expected,  as 
may  also  the  person  examining.  The  best  way  to  break 
the  current  is  at  the  battery  or  switchboard.  If  a  battery 


M.  gluteus  maximus 

""       (great  sciatic). 


M.  biceps  fern, 
(cap. 'long.) 
(grt.  feciat.). 


M.  biceps  feni. 
(cap.  brev.) 
(grt.  sciat.). 


N.  peroneus.  ••  — 


-  N.  ischiadicus. 

M.  adduct.  magnus  (n.  obt.). 
M .  semitendinosus  (grt. v 

sciat.). 

M.  semimembranosus 
(grt.  sciat.). 


N.  tibialis. 


M .  gastrocnem.  (cap. 

extr.). 

M.  gastrocnem.  (cap. 
int.). 


M.  soleus. 


M.  flex.  dig.  c-omm. long. 
M .  flexor  hallucis  longus. 

X.  tibialis. 


FIG.  154.—  MOTOR  POINTS  OF  THE  SCIATIC  XERVE  AND  ITS 
BRANCHES:  THE  PERONEAL  AND  TIBIAL  NERVES. 

be  used,  the  handle  of  the  collector  may  be  moved  off  and 
011  the  dummy  knob,  which  is  unattached  to  a  cell,  usually 
the  second  knob  of  the  collector.  If  the  collector  is  a  single 
one,  then  we  may  use  the  de  Watteville  commutator. 

Reaction  of  Degeneration. — This  occurs  in  a  nerve  when 
it  is  severed  or  is  the  seat  of  acute  inflammation.^  When  it 
sets  in,  the  application  of  a  faradic  current  over  the  muscle 


GALVANO-FARADISM 


307 


OUurntor  n. 
M.  pectlneus 


V.  adductor  magnns —  i 
M.  ajiluct.  (outrun  — 


M.  vHstus  Internus  1 

K^       I 


M.  tensor  fascia;  fumoris 


M.  qundrlcops  femnris 
(common  point) 


M.  rcetus  fomoris 


XI.  Tustus  cxtcnms 


FIG.  155. — MOTOR  POINTS  OF  THIGH. 


M.  tibial.  antic.  - 


il.  eitccs.  digit,  comm. 
long. 


M.  jicroucus  brc7is 


M,  extensor  halluoia 
long. 


Mm.  laterossei  dorsales 


v    «\- —  M-  gastrocnem.  external  heaii 
M.  peroneua longua 


M.  fieior  hallucis  long. 


M.  eitcna.  digit,  comm. 
brevis 


M.  abductor  digiti  mln. 


FIG.  156. — MOTOR  POINTS  OF  LEG. 


308         MANUAL  OF  PHYSIO -THERAPEUTICS 

or  motor  point  no  longer  produces  any  contraction  even 
with  a  very  strong  current.  A  galvanic  current  also  fails 
to  produce  the  quick  twitch  characteristic  of  normal  muscle. 
A  sluggish  contraction,  slow  to  develop  and  slow  to  relax, 
is  seen,  often  larger  than  would  be  produced  in  a  normal 
muscle  by  the  same  strength  of  current.  The  response 
comes  from  the  altered  muscle,  and  not  from  the  stimulation 
of  the  nerve-endings  in  it;  it  is  known  as  hyperexcitability 
to  galvanism.  This  condition  is  usually  established  about 
the  third  week  after  the  lesion  has  taken  place.  After  two 
or  three  months  the  response  to  galvanism  also  fails,  though 
for  a  year  or  more  an  anodal  closing  contraction  may  be 
obtained  by  a  gradually  increasing  strength  of  current. 

If  the  lesion  does  not  involve  complete  severance  of  the 
nerve  or  ablation  of  the  centre,  then,  of  course,  there  are 
all  varieties  and  degrees  of  the  above. 

The  Use  of  Galvanism. — As  a  preliminary,  all  switches 
must  be  examined,  the  crank  collector  be  at  zero,  reversing 
switch  at  N,  and  the  galvanometer  shunt  adjusted  for  the 
strength  of  current  we  are  likely  to  use — to  register,  that  is, 
in  units  or  tens,  as  the  case  may  be.  Cords  must  be  in 
good  order,  and  metal  ends  clean  and  free  of  verdigris.  It 
is  usual  to  employ  a  green  cord  for  the  negative  and  a  red 
cord  for  the  positive.  Electrodes  must  be  firmly  attached, 
and  before  starting  the  operator  should  test  the  current  on 
his  own  hand. 

The  patient  should  be  seated  or  lying  in  a  comfortable 
position,  with  the  parts  to  be  treated  well  supported  and 
the  clothes  guarded  by  towels  or  waterproof  fabric.  The 
electrode  should  not  be  applied  over  any  skin  abrasion,  or, 
if  so,  they  should  be  protected  by  collodion  or  adhesive 
plaster.  As  mentioned  above,  the  pads  or  leather-covered 
electrodes  are  soaked  in  alkaline  hot  water,  and  carefully 
and  firmly  applied.  The  limb  or  part  treated  should  be 
as  far  as  possible  protected  from  the  cold  when  treated. 

The  current  is  turned  on  very  slowly  from  peg  to  peg 
when  a  battery  is  used,  or  the  resistance  cut  slowly  out 
in  a  switchboard.  The  patient  has  no  painful  sensation 
normally,  but  a  slight  pricking  feeling,  to  which  he  soon 
gets  accustomed. 


GALVANO-FARADISM  309 

The  various  ways  of  application  are  bipolar  and  unipolar 
galvanism. 

(1)  In  bipolar  both  the  positive  and  negative  electrode 
are  placed  on  the  part  being  treated. 

(2)  In  unipolar  only  one  pole  is  used  in  the  treatment  of 
the  condition,  and  is  known  as  the  active  electrode.     The 
other  pole  is  referred  to  as  the  indifferent  electrode,  and 
merely  used  to  complete  the  circuit,  being  applied  to  some 
remote  part  of  the  body  or  through  a  foot  bath. 

Treatment  may  be,  further,  stabile  or  labile.  The  former 
is  the  most  common,  perhaps.  But  with  labile  we  move 
the  electrode  up  and  down,  either  in  the  form  of  a  roller 
or  sponge  or  disc  electrode  which  has  been  soaped. 

General  Galvanism  is  applied  all  over  the  body,  but  is 
perhaps  best  applied  by  means  of  a  galvanic  Schnee  bath. 

Central  Galvanism  is  a  valuable  form  of  treatment  in 
neurasthenia  and  functional  troubles.  In  it  a  large  flat 
electrode  is  attached  to  the  negative  pole  and  applied  over 
the  hypogastrium  just  above  the  navel,  while  the  positive 
pole  is  applied  by  means  of  a  small  disc  electrode  to  the 
forehead  and  vertex.  The  current  should  be  a  low  one 
of  about  3  to  5  milliamperes.  After  the  forehead  and 
vertex  have  been  treated  for  about  five  minutes  each,  the 
electrode  may  be  then  passed  up  and  down  the  spine  for  a 
further  ten  minutes,  the  current  being  allowed  to  increase 
up  to  10  milliamperes. 

Faradism  :  Method  of  Application. 

Faradism  is  free  of  all  danger  of  burning,  and  the  only 
pain  it  causes  is  by  overstimulation  of  a  muscle,  causing 
cramp,  which,  however,  is  easily  allayed  and  easily  avoided 
with  care.  It  is  used  for  various  purposes. 

1.  For  skin  stimulation,  when  a  brass- wire  brush  is  applied 
directly  to  the  skin  by  the  labile  method,  with  a  large  flat 
plate  as  the  indifferent  electrode. 

2.  It  may  be  conveniently  applied  by  the  Schnee  four-cell 
bath  to  the  whole  body,  or  by  means  of  the  masseur's  hand 
in  electric  massage,  which  is  an  exceedingly  effective  way 
of   stimulating   the   muscles  and  system  generally.     As  a 


310        MANUAL  OF  PHYSIO-THERAPEUTICS 

rule  this  is  preferable  to  the  use  of  an  electrode  by  the  labile 
method,  in  which  the  electrode,  well  lubricated  with  soap, 
is  moved  up  and  down  the  body  surface. 

3.  The  surging  treatment  has  been  of  great  use  in  the 
treatment  of  soldiers  suffering  from  wounds  involving  the 
severance  of  nerves,  which  have  been  sutured,  involving  the 
very  considerable  wasting  of  muscle.  Fairly  strong  currents 
are  applied  over  large  areas.  If  the  leg  is  being  treated, 
one  electrode  is  on  the  thigh  and  the  other  the  ankle. 
They  are  carefully  bandaged  on.  The  current  is  weak  at 
first,  gradually  increased,  and  then  rhythmically  increased 
and  decreased.  This  surging  effect  is  effected  in  the  very 
largely  used  Bristow  battery  by  pushing  the  iron  core  in 
and  out,  and,  if  a  sledge  coil  be  used,  by  moving  the  secon- 
dary backwards  and  forwards. 

An  apparatus  worked  by  a  cam  and  motor  is  the  most 
efficient  and  the  sensation  most  agreeable;  no  pain  is 
caused  the  patient  by  the  periodic  fluctuation  of  the 
current. 

Primary  and  Secondary  Currents. — A  general  rule  was  laid 
down  by  Duchenne  that  the  primary  current  is  best  adapted 
for  the  stimulation  of  deep-lying  organs  such  as  the  stomach, 
bladder,  and  rectum,  while  the  secondary  currents  are  best 
suited  for  the  stimulation  of  cutaneous  nerves  and  the 
muscular  system.  The  primary  current  is,  generally  speak- 
ing, best  for  the  Schnee  bath. 

The  Technique  of  Faradization. 

The  faradic  current  may  be  applied  locally  or  generally, 
and  by  the  stabile  or  labile  methods. 

The  electrodes  are  similar  in  character  to  those  used  for 
galvanism,  but  there  are  some  special  types,  such  as  the 
wire  brush  electrode.  The  sponges  or  leather  covering 
should  be  moistened  with  salt  and  water,  or  if  the  sensory 
nerves  are  to  be  treated  the  skin  should  be  dusted  with 
cimolite  or  starch  powder. 

The  large  indifferent  electrode  should  be  placed  at  some 
remote  part,  such  as  the  lumbar  muscles,  or  the  patient 
should  hold  it  in  his  hand. 


GALVANO-FARADISM  311 

General  Faradization  brings  every  portion  of  the  body 
under  the  influence  of  the  current  so  far  as  is  possible  by 
outward  applications. 

The  patient  should  be  seated  on  a  stool  facing  the  instru- 
ment, and  for  the  first  part  of  the  process  should  be  stripped 
to  the  waist,  and' have  his  shoes  and  socks  removed;  his 
feet  should  be  placed  against  a  copper  sheet  warmed  by 
means  of  a  hot- water  bottle ;  the  surface  should  be  moistened 
with  warm  water,  and  it  should  be  connected  with  the 
negative  pole  of  the  battery.  If  the  patient  is  paralyzed, 
he  may  lie  on  a  couch  with  the  copper  plate  beneath  his 
buttocks.  The  other  electrode  consists  of  a  brass  ball 
(6  inches  diameter)  covered  with  damp  wash-leather  or  felt, 
or  the  moistened  hand  of  the  operator,  connected  with  the 
anode. 

When  the  hand  is  used  as  the  active  electrode,  the  covered 
brass  ball  electrode  should  be  held  in  the  other  hand,  or 
allowed  to  rest  on  a  table  and  be  lightly  touched  at  first 
with  the  other  hand.  The  strength  of  the  current  can  then 
be  gauged  by  the  operator's  own  sensation,  and  the  flexi- 
bility of  the  hand  allows  of  easy  adaptation  to  varying 
surfaces.  A  very  mild  current  should  be  used  at  first,  and 
gradually  increased. 

The  moistened  hand  should  be  first  applied  to  the  patient's 
forearm,  and  the  circuit  then  completed  by  placing  the 
other  hand  on  two  covered  brass  electrodes — the  positive 
pole.  The  hand  is  then  passed  over  the  moistened  hair 
of  the  patient's  head,  over  his  neck,  throat,  up  and  down 
the  spine,  arms,  and  hands,  then  the  surface  of  the  abdomen, 
and  finally  the  legs.  Duration  of  seance,  from  five  to 
twenty-five  minutes;  fifteen  minutes  is  a  very  average 
time,  apportioned  in  the  following  manner: 

Head  .  .  .  .  1  minute. 

Neck  and  throat          •  .  4  minutes. 

Upper  and  lower  extremities  ..      4         ,, 
Abdomen      . .              .  .  3         ,, 

Back  . .  . .  . .     3         „ 

The  treatment  is  applied  about  three  times  a  week,  the 
length  of  the  course  entirely  depending  on  the  chronicity 


312        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  nature  of  the  case  dealt  with.  After  the  treatment  the 
patient  feels  considerably  invigorated,  the  sensation  of 
exhilaration  continuing  for  several  hours;  sometimes  drowsi- 
ness results.  The  pulse  is  steadied,  depression  relieved, 


FIG.  157. — ELECTRIC  MASSAGE. 

The  current  is  here  led  from  the  main — after  suitable  resistance  has 
been  interposed — by  a  cord  (not  seen  in  illustration)  to  the 
spongio-piline  pad  under  the  operator's  left  hand.  The  patient 
lies  on  the  negative  (plate)  electrode.  It  is  often  preferable  for 
the  operator  to  draw  the  current  from  a  moist  sponge  electrode 
which  he  holds  with  varying  firmness  in  one  hand,  while  he  uses 
the  other  hand  as  an  electrode,  and  with  it  massages  the  patient. 
In  this  manner  current  strengths  can  be  graduated  with  much  pre- 
cision, and  faradism  can  be  rendered  extremely  agreeable  and 
painless.  The  flexibility  of  the  hand  and  its  adaptability  to 
any  surface  of  the  body  renders  it  a  most  excellent  electrode. 

appetite  and  digestion  improved,  and  muscular  energy  and 
body-weight  increased.  Sometimes  there  is  slight  soreness 
of  the  muscles. 


GALVANO-FABADISM  313 

THERAPEUTIC  INDICATIONS. — General  faradization  is  use- 
ful in  the  treatment  of  various  functional  nerve  diseases, 
such  as  hysteria,  neurasthenia,  and  nervous  dyspepsia, 
It  improves  the  tissues  of  the  muscles  in  various  paralytic 
conditions,  and  takes  the  place  of  exercise  and  massage. 

Galvano-Faradization. — The  combined  use  of  galvanic  and 
faradic  current,  as  suggested  by  de  Watteville,  is  effected 
by  uniting  the  secondary  induction  coil  and  galvanic  battery 
in  one  circuit,  by  connecting  with  a  wire  the  negative  pole 
of  the  one  with  the  positive  pole  of  the  other;  the  electrodes 
are  attached  to  the  two  extreme  poles,  and  both  currents 
are  sent  through  the  body.  The  special  key  of  de  Watte- 
ville is  useful  in  this  combination.  The  effect  of  this 
combined  current  is  at  once  stimulating  and  soothing. 

The  Condenser  System  for  Muscle-Testing. 

The  late  Lewis  Jones  suggested  this  procedure,  which 
has  received  considerable  attention  of  late  years  in  war 
hospitals  as  a  means  of  stimulating  partially  paralyzed 
nerves  and  muscles.  It  is  an  alternative  to  using  interrupted 
galvanic  currents  by  the  Leduc  interrupter  or  faradic 
currents  from  an  induction  coil.  The  claim  for  superiority 
lies  in  the  fact  that  neither  of  these  can  be  properly  measured, 
and  that  therefore  no  record  can  be  kept,  so  as  to  give  just 
the  same  treatment  in  any  other  case. 

From  no  faradic  coil,  either,  can  an  impulse  so  short  as 
^Tiiocr  of  a  second  be  obtained,  which  can  be  effected  with 
the  condenser  system.  There  is  no  difficulty  either  in 
calculating  the  time  which  any  condenser  discharge  lasts; 
and,  further,  by  arranging  a  system  of  known  capacities  and 
charging  at  a  known  voltage,  we  have  at  once  a  system  by 
means  of  which  muscle-testing  can  be  carried  out  and  the 
results  accurately  recorded  in  terms  of  the  discharge,  noting 
the  times  necessary  to  give  response  in  any  individual  case. 

Jones's  apparatus  has  been  modified  by  Dr.  Hernaman 
Johnson,  so  that  the  system  can  be  used  for  faradization 
without  any  alteration.  The  metronome  used  is  motor- 
driven,  and  so  airanged  that  its  speed  can  be  varied  from 
one  impulse  every  two  seconds  to  about  600  per  minute 


314        MANUAL  OF  PHYSIO-THERAPEUTICS 

for  treatment  purposes.  At  the  latter  speed  effects  are 
obtained  very  similar  to  those  given  by  a  faradic  coil,  but 
we  have  the  advantage  of  accurate  measurement,  the 
number  of  impulses  being  shown  by  a  speed-counter  attached 
to  the  spindle  of  the  metronome. 

The  various  studs  of  the  regulation  switch  are  engraved 
with  the  discharge  times  which  are  obtained  from  Lewis 
Jones's  original  paper,  and  are  based  on  the  assumption 
that  the  patient's  resistance  is  1,000  ohms.  Three  addi- 


FIG.  158. — LEWIS  JONES  CONDENSER  TESTING  SET. 

tional  studs  are  provided,  making  fifteen  in  all,  and  give 
a  capacity  of  2  microfarads. 

When  the  apparatus  is  worked  from  a  200- volt  circuit,  the 
100  volts  necessary  for  charging  under  ordinary  circum- 
stances are  obtained  by  connecting  two  similar  incan- 
descent lamps  in  series,  and  taking  the  wires  from  one  only 
to  the  condenser  apparatus. 

If  there  is  difficulty  in  obtaining  a  response,  and  it  is 
necessary  to  charge  at  double  the  voltage,  as  advised  by 
Lewis  Jones,  the  primary  connections  must  be  altered  so 


GAL  7ANO-FARADISM 


315 


as  to  use  the  full  200  voltage.     The  patient's  circuit  must 
also  be  adjusted  so  as  to  include  5,000  ohms  resistance. 

These  adjustments  are  rendered  unnecessary  in  the  newer 
type  of  apparatus,  and  all  the  necessary  alterations  are 
made  automatically  when  the  handle  is  passed  from  the 
twelfth  to  the  thirteenth  stud.  Nos.  13,  14,  and  15  are 
repetitions  of  the  previous  three  so  far  as  capacities  are 
concerned,  but  charged  and  discharged  under  new  con- 


FIG.   159. — HERXAMAX  JOHXSOX  MODIFIED  COXDEXSER 
APPARATUS. 

ditions.  There  are  therefore  a  series  of  fifteen  different 
periods  of  increasing  lengths  of  discharge  duration,  all 
controlled  by  the  movement  of  one  handle,  so  that  the 
manipulation  is  fairly  simple.* 

The  metronome  is  arranged  with  two  beams  which  makes 
the  apparatus  earth-free.     It  is  provided  with  a  voltmeter 

*  For  further  details,  see  Lancet,  February  19,  1916. 


316        MANUAL  OF  PHYSIO-THERAPEUTICS 

to  calibrate  the  set  when  first  installing,  so  as  to  give 
accurately  100  volts  for  the  first  twelve  studs  and  200  for 
the  final  three.  It  is  suited  for  any  direct-current  circuit 
of  200  to  250  volts. 

A  further  modification  is  the  addition  of  a  mercury- jet 
interrupter  arranged  to  charge  and  discharge  a  variable 
condenser,  and  the  motor  which  drives  the  interruptei  also 
operates  a  liquid  rhythmic  interrupter,  through  which  the 
discharge  is  passed  to  the  patient.  The  current  is  very 
pleasant  to  take,  and  perfectly  even. 


CHAPTER  II 
THE    DYNAMO 

WHEN  dealing  with  currents  from  the  main  it  is  highly 
important  to  have  some  conception  of  the  structure  and 
manner  of  working  of  the  dynamo  by  means  of  which  the 
electric  current  is  most  commonly  generated.  Electric 
current  in  reality  is  but  the  conversion  of  another  form  of 
energy  into  electrical  energy,  and  the  prime  motive  power 
may  be  either  water,  motor  or  turbine  steam  engine,  steam 
turbine,  gas  or  oil  engine,  etc.,  entirely  depending  on  cir- 
cumstances. Water-power  is  greatly  favoured  where  the 
natural  lie  of  the  land  is  such  as  to  provide  abundant  river 
falls,  etc.,  such,  for  instance,  as  in  Canada,  United  States, 
and  other  parts  of  the  Continent.  One  of  the  best  instances 
of  harnessing  such  natural  powers  is  to  be  found  in  the 
Niagara  Falls  of  North  America,  where  there  is  an  installa- 
tion with  a  distributing  voltage  in  the  neighbourhood  of 
60,000  volts,  which  is  spread  over  large  areas  by  a  network 
of  wires  supplying  lighting  and  power  for  commercial 
purposes  at  suitable  voltages.  In  Great  Britain,  owing  to 
the  paucity  of  large  river  falls,  steam  power,  either  in  the 
form  of  steam  engine  or  turbine,  is  the  most  favoured,  coal 
being,  generally  speaking,  comparatively  abundant  in  many 
districts.  Gas  and  oil,  however,  are  coming  into  use,  and 
find  favour  for  special  installations  where  the  electric  power 
is  required  for  manufacturing  and  other  purposes.  The 
dynamo  consists  of  two  main  parts,  no  matter  whether 
intended  to  give  alternating  or  direct  current — viz.,  the 
stator  and  the  rotar.  The  former,  in  the  case  of  the  ordinary 
direct-current  machines,  is  called  the  field  magnet,  the 
latter  the  armature.  The  armature  is  composed  of  sheets 
of  laminated  iron  around  which  is  wound  coils  of  insulated 
copper  wires,  generally  in  specially  prepared  slots  to  receive 

317 


318        MANUAL  OF  PHYSIO -THERAPEUTICS 

same.  The  ends  of  this  wire  are  connected  with  two  copper 
rings  fixed  to  and  insulated  from  the  axis  or  the  shaft  of 
the  armature,  or  to  what  is  called  a  commutator,  which  is 
composed  of  a  cylinder  divided  up  into  a  number  of  sections, 
depending  on  the  arrangement  of  the  windings  on  the 
armature.  Collecting  brushes  rub  against  the  rings  or 
commutator,  and  connect  the  machine  with  the  external 
circuit  wherein  the  power  is  to  be  absorbed. 

In  most  modern  direct- current  dynamos  there  are  four, 
six,  eight,  or  more  pairs  of  poles,  depending  on  the  speed  the 
dynamo  armature  rotates  at  when  giving  its  maximum 
voltage,  this  being  limited  to  the  design  of  the  steam  or 
other  engine  which  will  have  to  drive  the  same.  In  the  case 
of  large  outputs  multipolar  machines  have  many  advantages. 
When,  however,  we  are  dealing  with  alternating  currents, 
the  number  of  poles  is  a  factor  upon  which  the  periodicity 
depends,  especially  where  high  values  and  limited  engine 
speeds  are  concerned.  The  field  magnetism  may  be  main- 
tained in  a  variety  of  ways:  (1)  By  permanent  magnets, 
which,  however,  now  have  very  limited  application,  and 
are  chiefly  to  be  found  in  telephone  circuits  and  in  the 
magnetos  of  motor-cars  for  ignition  purposes.  (2)  The 
magneto  may  be  of  soft  iron,  and  independently  excited  by 
batteries,  but  the  most  common  way  is  self-excitation — 
that  is,  the  armature  is  connected  either  in  series  or  shunt 
with  the  armature.  This  presumes,  however,  that  there 
is  a  certain  amount  of  residual  magnetism  remaining  in  the 
iron  of  the  field  magnet ;  if  not,  a  momentary  current  must 
be  passed  through  the  same,  and  in  both  cases  the  action 
is  as  follows:  The  armature  as  it  rotates  in  even  a  weak 
field  moves  current  which  passes  round,  the  exciting  of  the 
field  coils  tending  to  strengthen  same,  the  effect  of  which 
is  to  increase  the  induced  E.M.F.  of  the  armature  until  its 
full  pressure  is  obtained,  which  will  result  in  a  maximum  of 
excitation.  Great  care  must  be  taken  to  see  that  the 
current  flowing  from  the  armature  passes  in  the  correct 
direction  around  the  field — that  is  to  say,  in  such  direction 
as  to  strengthen  same  and  not  to  neutralize  it.  There  are 
two  usual  ways  of  connecting  the  armature  to  the  fields  for 
excitation  purposes — shunt  and  series  winding.  In  the 


THE  DYNAMO  319 

shunt  the  full  output  of  the  armature  is  applied  to  the  field, 
and  only  a  small  fraction  of  current  generated;  it  passes 
around  the  field  many  times,  rendering  it  very  powerful; 
or,  in  other  words,  a  fixed  number  of  ampere  turns.  It 
might  be  here  stated  that  the  strength  or  number  of  lines 
of  force  of  a  magneto  depends  on  the  product  of  the  current 
and  the  number  of  turns  of  wire. 

The  other  method  is  known  as  the  series  excitation — that 
is,  the  field  varies  with  the  value  of  the  armature  current, 
which  the  speed,  being  constant,  varies  as  the  external 
resistance  of  the  load. 

When  dealing  with  motors,  the  matter  of  series  or  shunt 
wound  construction  is  a  very  important  one.  The  shunt 
connection  gives  a  practically  uniform  speed  irrespective 
of  the  load,  so  long  as  the  latter  is  within  the  limits  of  the 
machine  specified;  on  the  other  hand,  with  the  series  arrange- 
ment the  speed  varies  with  the  load,  being  slow  with  a 
heavy  load  and  fast  with  a  light  one. 

Current  from  the  Main. 

Once  X  rays  came  into  general  use,  electrical  methods 
changed  entirely,  and  means  had  to  be  found  for  harnessing 
high  voltage  currents  from  the  main  for  electro-therapeutic 
purposes.  The  electric  current  is  not  generally  available 
in  both  small  and  large  towns;  in  the  latter  the  voltage  is 
generally  200  to  250,  either  direct  or  alternating  in  character 
—in  the  latter  case  the  periodicity  varying  from  40  to 
100  periods  per  second.  In  many  towns  both  types  of 
supply  are  to  be  found.  From  a  medical  or  electro-thera- 
peutic point  of  view  the  continuous  current  has  advantages, 
but  where  X-ray  work  is  concerned  and  powerful  apparatus 
is  required  has  now  become  more  popular,  as  it  reduces  the 
primary  cost.  The  alternating  current  is  in  large  towns 
distributed  at  a  very  high  voltage,  of  2,000  to  10,000  in 
many  cases,  and  as  the  cable  enters  each  house  it  passes 
through  a  step-down  transformer  in  which  it  is  converted 
down  to  100  or  200  volts.  Sometimes  the  reduction  is 
effected  in  substations. 

The  advantage   of   this   system   to   the   electric   lighting 


320        MANUAL  OF  PHYSIO -THERAPEUTICS 

companies  lies  in  the  fact  that  the  copper  cables  employed 
for  the  mains  need  be  only  TV  to  i^  of  the  thickness  required 
for  the  distribution  of  the  same  quantity  at  low  voltage. 

The  number  of  amperes  which  a  cable  can  carry  without 
becoming  hot  is  limited,  and  ought  not  to  exceed  1,000 
amperes  per  square  inch  (cross-section)  of  copper.  The 
number  of  volts,  however,  can  be  raised  as  far  as  the  safety 
of  the  insulation  permit;  as  many  as  30,000  volts  have 
been  used  in  wires  suspended  on  porcelain  insulators  on 
telegraph-poles  and  sent  over  a  distance  of  more  than 
100  miles.  A  copper  cable  with  a  cross-section  of  1  square 
inch  can  carry  100,000  watts  only  with  100  volts,  but 
5,000,000  watts  with  5,000  volts.  The  net  gain  to  the 
electric  company  from  the  commercial  point  of  view  is  not 
nearly  so  great  as  the  figures  imply,  because  the  cables  for 
5,000  volts  require  a  much  better  insulation  than  those  for 
200  only.  Further,  accumulators  cannot  be  used  with  the 
alternating  current,  and  the  engines  therefore  have  to  be 
kept  running  all  day,  and  there  is  ultimately  some  loss  in 
the  transformers  fixed  in  the  consumers'  houses  whenever 
the  current  is  not  being  used.  Notwithstanding  all  this, 
the  alternating  current  requires  to  be  employed  whenever  it 
is  to  be  sent  over  long  distances. 

The  constant  current  or  direct  current  is  necessary  for 
ordinary  electro-therapy,  ionization,  electrolysis,  etc. 

It  is  obvious  that  the  nature  of  the  supply  in  any  town 
will  depend  on  factors  such  as  water-power,  coal-supply,  etc. 

Transformers. — These  are  of  two  kinds — static  and  motor. 

The  Static  or  stationary  transformer  is,  strictly  speaking, 
an  alternating-current  machine,  and  is  usually  placed  in  the 
cellar  of  a  house  drawing  its  supply  from  a  high- voltage  main 
in  the  district;  the  apparatus  is  covered  by  wire  protector 
of  some  sort  to  secure  that  people  who  are  ignorant  of  its 
nature  do  not  cause  themselves  severe  shocks  or  other  injury, 
as  the  current  running  through  the  supply  wires  may  exceed 
1,000  volts.  This  is  what  is  called  a  step-down  transformer. 

A  small  stationary  transformer  may  be  used  also  for 
attachment  to  a  wall  entirely  to  isolate  the  current  and 
adjust  the  voltage  for  special  purposes. 

Motor    Transformers   are    of    two    kinds.     The   rotatory 


THE  DYNAMO  321 

converter  is  the  most  handy  and  compact  form  of  machine 
for  obtaining  an  alternating  current  from  a  direct -current 
supply,  and  is  used  in  the  production  of  sinusoidal  or  poly- 
phase currents  (see  section  dealing  with  these). 

Motor  Transformers. — These  are  of  two  types,  the  first 
is  known  as  a  rotary  converter,  and  is  generally  used  for 
converting  direct  current  into  alternating,  but  may  be 
used  vice  versa,  provided  same  is  suitably  constructed.  In 
design  it  is  really  a  motor  the  armature  of  which  has  a  pair 
of  rings  insulated  from  each  other  mounted  on  the  end  of 
the  shaft,  and  for  convenience  at  the  commutator  side,  and 
connected  to  two  points  of  the  armature  winding — for 
example,  in  the  case  of  a  two-pole  machine  to  the  two 
opposite  bars  of  the  commutator;  upon  these  rings  slide 
two  bushes,  to  which  the  external  circuit  is  connected. 
These  machines  are  excellently  adapted  for  cautery  and 
light  work,  and  for  giving  sinusoidal  current  when  the 
supply  main  is  direct  current.  It  is,  of  course,  necessary 
to  introduce  a  small  static  transformer  with  suitable  ratio 
of  winding  between  primary  and  secondary,  so  as  to  obtain 
the  correct  voltage  and  current  for  each  particular  purpose. 
This  transformer  has  the  further  property  of  rendering  the 
machine  earth-free  when  the  direct-current  main  is  a  three- 
wire  system  with  middle  wire  earthed. 

The  second  type  is  called  a  motor  generator,  and  in 
general  practice  is  used  for  transforming  direct  current  at 
one  voltage  into  either  a  lower  or  higher  voltage.  It  may 
consist,  first,  of  one  machine,  as  described  under  rotary 
converters,  provided  with  an  entirely  separate  winding 
wound  in  the  same  armature  slots  and  attached  to  a  separate 
commutator,  which  may  also  have  rings  for  taking  ofv 
alternating  current.  In  the  case  of  the  rotary  converter 
011  direct  current  there  is  a  definite  ratio  between  the  input 
voltage  and  the  output  voltage,  whereas  in  the  case  of  the 
motor  generator  the  voltage  may  be  anything  within  limits, 
just  depending  on  the  special  winding.  Tliis  type  of  machine 
has  come  to  be  used  largely  in  medical  work  under  the 
name  of  universal  apparatus,  which  is  usually  arranged  to 
give  suitable  currents  for  cautery  and  light  purposes,  direct 
current  for  galvanism,  and  sinusoidal  alternating  current, 

21 


322        MANUAL  OF  PHYSIO-THERAPEUTICS 

all  of  which  are  entirely  earth-free,  even  although  the  motor 
acts  on  an  earthed  system.  In  the  second  type  of  machine, 
when  transforming  from  direct  current  of  one  voltage  to 
another,  we  have  a  separate  motor  running  on  the  main 
supply,  and  mechanically  coupled  to  same  is  a  separate 
generator  the  windings  of  which  are  arranged  for  the 
particular  voltage  required;  if  alternating  current  is  re- 
quired, the  generator  is  further  supplied  with  rings.  This 
machine  also  lends  itself  for  the  purpose  of  converting 
alternating  current  into  direct  current  at  the  required 
voltage.  In  this  case  the  motor  may  be  a  three-phase  one 
or  a  single-phase  repulsion  motor  depending  on  the  supply 
system,  which  is,  as  before,  mechanically  converted  to  a 
direct-current  generator. 

The  Safety  of  using  Currents  from  the  Main. — If  a  shunt 
rheostat  and  lamp,  as  described  below,  be  used,  it  is  scarcely 
possible  for  the  patient  to  receive  too  powerful  a  current— 
that  is,  a  dangerous  shock.  Of  course,  the  current  may  be 
turned  on  by  mistake  while  the  spring  of  the  rheostat  is 
"  strong  "  instead  of  "  weak,"  just  as  this  can  happen 
while  the  current  collector  of  the  battery  is  still  full  on. 
In  both  instances  a  very  unpleasant  but  not  dangerous 
shock  will  be  given.  With  the  usual  system  of  underground 
cables,  the  E.M.F.  of  a  continuous  current  never  rises 
suddenly  to  dangerous  proportions. 

In  most  installations,  however,  owing  to  defective  insula- 
tion, there  is  a  certain  amount  of  leakage  or  escape  of 
electricity  to  earth  (Fig.  160).  If  the  three- wire  system  be 
used,  and  the  positive  pole  of  the  dynamo  is  connected 
with  earth,  a  patient,  also  in  good  earth  contact,  may 
receive  a  shock  when  the  electrode  is  applied,  even  if  there 
is  ample  resistance,  or  if  this  electrode  happens  to  be 
connected  with  the  negative  pole  of  the  dynamo.  Such 
shocks  practically  never  occur,  owing  to  patients  being 
usually  well  insulated  from  the  earth  by  a  carpet  or  dry 
wooden  floor.  Operators  have  received  unpleasant  shocks 
from  holding  an  electrode  in  one  hand,  while  they  attempted 
with  the  other  to  open  a  water  tap  to  moisten  the  electrodes. 
It  must  be  made  a  rule  not  on  any  account  to  touch  gas  or 
water  pipes  so  long  as  one  hand  is  in  contact  with  the 


THE  DYNAMO 


323 


switchboard  or  an  electrode.     There  is  really  no  danger  in 
local  applications  of  the  current  if  this  rule  is  adhered  to. 

The  case  is,  however,  different  if  the  current  is  to  be 
applied  in  a  bath.  A  patient  might  receive  even  a  fatal 
shock  if  the  necessary  precautions  are  neglected.  The 


JI   tQ  ezrfhed 

|  -1  I  nevfral pole. 


asle  pipe  formino 

te  ~ 

connection 


idle  (-)  pole. 


FIG.  160.  —  SCHEME  OF  ELECTRIC  BATH  CIRCUIT  TO  SHOW  now 
SHORT-CIRCUITING  MAT  TAKE  PLACE  BY  MEANS  OF  THE  EARTH 
CONTACT  WITH  WASTE  PIPE. 

water  in  a  bath  tub,  even  if  the  latter  is  made  of  porcelain, 
is  usually  in  excellent  contact  with  the  earth  through  the 
waste  pipes,  etc.,  which  are  of  metal.  If  the  current  is 
intended  to  be  applied  in  a  bath,  it  is  necessary  to  insulate 
the  water  by  replacing  the  metallic  waste  pipes  by  others 

Waste  Pipe 
u/jffi 


FIG.   161. 

made  of  earthenware  for  a  considerable  distance,  or,  better, 
to  let  the  bath  discharge  pipe  run  into  an  open  gully  con- 
nected with  a  main  waste  pipe  (Fig.  161);  by  enclosing  the 
inlet  pipes  and  taps  in  wooden  cases  so  that  the  patient 
cannot  possibly  touch  them;  and  by  use  of  a  bath  tub  made 
of  porcelain  or  wood.  If  this  cannot  be  done,  the  metal 


324        MANUAL  OF  PHYSIO-THERAPEUTICS 

bath  must  be  at  least  placed  on  tiles  of  porcelain.  If  the 
leakage  is  bad,  or  if  one  pole  of  the  mains  is  earthed,  there 
should  be  no  current  reverser  on  'the  switchboard.  If  the 
current  is  used  for  an  electric  bath  in  a  hospital  or  hydro- 
pathic, it  is  advisable  to  transform  it  by  means  of  a  small 
motor  transformer.  This  applies  to  a  full  hydro-electric 
bath.  But  even  with  a  Schnee  four-cell  it  is  necessary  to 
secure  absolute  safety  for  the  patient. 


The  Switchboard. 

Given  a    supply   of   electrical   current   in    the   house   or 
establishment,   we  have   to  proceed  to  its  utilization  for 


WAT.SON 

FIG.   102. — THE  SWITCHBOARD. 

medical  purposes.  We  have  the  choice  of  using  a  switch- 
board for  direct  current,  or,  alternatively,  we  may  employ 
one  of  the  universal  apparatus,  such  as  the  multostat,  which 
are  earth-free.  This  is,  of  course,  a  very  great  advantage, 
and  these  apparatus  are  dealt  with  in  detail  on  p.  335  et  seq. 


THE  DYNAMO  .    325 

Prior  to  the  introduction  of  these  machines,  the  medical 
switchboard  for  galvanism  and  faradism  was  in  very  general 
use,  and  is  still  frequently  employed.  It  enables  the 
physician  to  treat  the  patient  by  means  of  regulated  amounts 
of  the  direct  current  through  a  shunt  circuit.  The  direct 
current  is  led  into  the  board  by  means  of  two  terminals, 
which,  of  course,  are  positive  and  negative  respectively. 

The  board  itself  is  now  usually  made  of  polished  marble  or 
slate.  Oak,  used  a  great  deal  formerly,  does  not  now  con- 
form to  the  Board  of  Trade  regulations.  The  following 
essential  parts  are  to  be  found  on  a  switchboard:  (1)  Re- 
sistance lamps,  or  the  equivalent;  (2)  safety  fuses;  (3)  a 
shunt  rheostat;  (4)  the  galvanometer;  (5)  induction  coil; 
(6)  de  Watteville  commutator;  (7)  reversing  switch;  (8)  ter- 
minals for  patient  and  supply. 

1.  The  Lamps. — These  serve  a   dual  purpose,  as  for  one 
thing  they  show  the  operator  at  a  glance  if  the  current  is 
passing  or  not,  but  the  main  function  is  to  act  as  a  means 
for  absorbing  the  greater  part  of  the  main  voltage,  leaving 
only  60  to  90  volts,  which  can  be  regulated  from  zero  to 
this  as  a  maximum  by  small  fractions  of  a  volt  at  a  time. 

2.  The  Fuse  is  merely  a  safety  valve  consisting  of  a  gap 
in  the  circuit  bridged  by  a  piece  of  tin  wire  of  such  size  as 
to  safety  carry  the  requisite  current,  and  which  will  fuse 
when   anything    occurs   to   unexpectedly   lower    the    fixed 
resistance,  and  thus  cause  damage  to  instruments,  etc.,  by 
excess  of  current. 

3.  The  Shunt  Rheostat. — This  is  practically  the  current 
"tap";   we  open  or  shut  it  or  adjust  it  at  will,  and  so 
regulate  the  amount  of  current  passing  to  the  patient  who 
is  being  treated  and  connected  directly  with  it.     It  consists 
of  a  core  of  slate,  around  which  some  500  or  more  turns  of 
resistance  wire  are  wound,  of  such  a  size  as  will  allow  of 
the  maximum  amount  of  current  desired.     The  voltage  is 
adjusted  by  means  of  a  metal  sliding  adjustment,  which 
rises  on  a  metal  rod  running  parallel  with  the  slate  core  and 
making  contact   with   the   surface   of   the  winding  at  any 
point.     In  the  above  diagram,   when  the  sliding  spring  is 
on  the  right  hand  near  B,  the  E.M.F.  between  the  terminals 
leading  to  the  patient  is  only  a  fraction  of  a  volt.     Put  in 


326 


MANUAL  OF  PHYSIO-THERAPEUTICS 


another  way,  the  resistance  through  the  rest  of  the  rheostat 
and  back  to  the  mains  is  small  compared  with  that  in  the 
shunt  circuit  containing  the  patient.  The  greater  portion 
of  the  current,  therefore,  takes  the  path  of  low  resistance, 
only  a  small  portion  reaching  the  patient. 


FIG.  163. — DIAGRAM  OF  SWITCHBOARD  WITH  LAMP  AND  WIRE 
RESISTANCE. 

If  the  spring,  however,  be  moved  slowly  to  the  left,  the 
resistance  of  the  circuit  through  the  rest  of  the  rheostat 
is  gradually  increased,  and  a  less  amount  of  current  passes 
along  it.  The  current  through  the  shunt  circuit  to  the 
patient,  on  the  other  hand,  is  proportionately  increased. 


FIG.  164. — THE  RHEOSTAT^ (FINE  WIRE). 

The  change  is  very  gradual,  and  increase  and  decrease  is 
made  much  smoother  if  the  sliding  spring  work  on  a  rack 
and  pinion. 

An  elementary  principle  in  beginning  is  that  we  start  with 
all  the  500  ohms  of  resistance  between  the  main  and  the 
patient,  and  then  slowly  cut  out  according  to  requirements. 
The  rheostat  is  marked  weak  011  the  left  side  and  strong  on 


THE  DYNAMO  327 

the  right,  so  mistakes  need  not  be  made.  If  the  precaution 
is  not  taken  to  see  the  spring  is  at  the  right  before  beginning, 
the  patient  may  sustain  a  dangerous  shock. 

There  are,  of  course,  various  types  of  rheostats.  That 
figured  above  is  most  commonly  used,  but  in  all  the  principle 
is  the  same.  Gaiffe  usually  fits  one  with  wire  windings 
standing  out  vertically  from  the  surface  of  the  board,  and 
the  cutting  out  is  arranged  by  means  of  a  movable  arm. 

4.  The  Galvanometer. — The  galvanometer  is  an  instru- 
ment in  the  strict  sense  for  indicating  the  presence  of  an 
electric  current,  and,  as  in  ionic  work  and  many  other  forms 
of  medical  treatment  with  electricity,  the  rate  at  which 
any  chemical  change  is  brought  about  by  means  of  the 
electric  current  is  dependent  upon  the  quantity  of  current 
passing  in  unit  time.  In  this  respect  the  ordinary  galvano- 
meter, even  the  most  delicate  in  construction,  is  not  much 
good  for  our  purpose,  as  in  medical  work  we  require  an 
instrument  which  will  read  directly  the  current  in  standard 
units,  and  to  obtain  this  it  is  necessary  to  use  particular 
types  of  instruments,  and  those  most  adapted  for  this 
purpose  are  the  instruments  wherein  the  zero  point  is 
unaffected  by  position  of  the  instrument — that  is,  it  ought 
to  be  able  to  work  in  a  horizontal  position  or  in  a  vertical 
one.  This  leaves  us  for  the  purpose  of  ionic  work,  utilizing 
continuous  current,  with  some  form  of  moving  coil  instru- 
ment, the  most  of  which  are  based  upon  the  d'Arsonval 
principle,  wherein  a  powerful  uniform  magnetic  fieldis secured 
by  means  of  a  horse-shoe  magnet  and  specially  shaped  pole 
pieces.  Moving  within  these  pole  pieces  is  a  coil  of  wire, 
generally  of  rectangular  shape  and  mounted  upon  pivots 
with  spiral  springs  to  maintain  the  coil  in  a  certain  position. 
When  a  current  is  passed  through  this  coil  it  tends  to  set 
itself  with  its  plane  so  as  to  include  the  greatest  number  of 
lines  of  magnetic  force.  As  this  work  is  not  intended  for 
dealing  with  the  construction  of  instruments,  we  will  proceed 
by  stating  that  a  milliamperemeter  as  above  can  be  made  to 
read  currents  as  small  as  one-thousandth  part  of  an  ampere, 
and  the  full  scale  in  most  cases  is  obtained  with  a  matter  of 
3  to  5  milliamperes.  Here,  again,  this  limit  of  current  is 
only  suitable  for  certain  testing  purposes  and  when  very 


328        MANUAL  OF  PHYSIO-THERAPEUTICS 

high  degree  of  accuracy  is  required.  For  general  treatment, 
however,  utilizing  ionic  work  with  either  large  pad  electrodes 
or  by  means  of  leg  and  arm  baths,  this  instrument  would 
be  too  sensitive.  The  instrument  is,  however,  so  arranged 
with  what  is  termed  a  shunt,  which  is  a  metallic  circuit 
capable  of  being  connected  across  the  moving  coil  of  the 
instrument  at  will,  so  that  only  a  fraction  of  the  actual 
current  passing  is  measured  on  the  instrument,  the  remain- 
ing part  going  through  the  shunt.  If,  however,  we  so 
arranged  the  shunt  as  to  have  a  definite  value  in  resistance 
to  that  of  the  moving  coil  itself,  such  as,  say,  one-ninth, 
one  ninety-ninth  part,  or  one  nine  hundred  and  ninety- 
ninth  part  of  the  moving  coil,  we  can  then  say  that  the 
reading  on  the  instrument — if,  for  instance,  we  close  the 
shunt  representing  one  -ninth  of  the  resistance  of  the  moving 
coil — has  the  multiplying  power  of  10;  that  is  to  say,  if 
the  current  passing  through  the  instniment  before  the  shunt 
was  attached  was  10  milliamperes,  then  on  closing  the 
shunt  representing  one-ninth  of  the  resistance  it  would  be 
found  that  the  instrument  needle  would  swing  back  and 
read  only  1  milliampere.  As,  however,  the  current  flowing 
through  the  moving  coil  operating  the  needle  represents 
one-tenth  of  the  current,  the  remaining  nine-tenths  passing 
through  the  shunt,  then  it  will  be  seen  that  the  instrument 
reading  requires  only  to  be  multiplied  by  10  to  give  the 
correct  reading.  This  becomes  very  simple  so  long  as  we 
stick  to  the  above  proportional  resi  stance  between  shunt 
and  moving  coil;  that  is  to  say,  using  one-ninth,  one  ninety- 
ninth,  and  so  on,  the  multiplying  power  is  respectively  10, 
100,  and  so  on.  The  older  forms  of  instruments  were  in 
most  cases  subject  to  terrestrial  magnetism;  that  is,  they 
had  to  be  laid  so  that  the  magnetic  needle  which  was  then 
used  was  lying  in  the  magnetic  meridian,  which  was  in 
reality  the  controlling  force  of  the  instrument.  If  the 
instrument,  however,  was  not  properly  placed  at  starting, 
the  reading  on  same  would  be  quite  incorrect. 

•">.  Induction   Coil  (see  p.  2KS  et  seq.,  under  "Faradism"). 

0.  The  de  Watteville  Commutator. — This  little  piece  of 
apparatus  (Fig.  165)  enables  us  to  change  quickly  from 
galvanic  to  faradic  current  without  having  to  alter  the 


THE  DYNAMO 


329 


connection  of  the  electrodes  or  terminals,  and  to  combine 
the  galvanic  with  the  faradic  current,  which  is  often  of 
considerable  value. 

If  the  cranks  point  to  G,  the  current  is  galvanic;  if  to  F, 
it  is  faradic;  while  if  it  lies  midway  between  we  are  using 


FK;.  11)5. — PE  WATTEVILLE  COMMUTATOR 

the  combined  or  do  Watteville  current,  so  named  after  the 
deviser  of  the  commutator. 

7.  Current  Reversers  and  Combiners. — It  is  important  for 
most  physicians  to  possess  an  arrangement  which  makes  it 
possible  suddenly  to  close  or  interrupt  the  current,  or  else 
suddenly  to  connect  with  the  negative  pole  the  electrode 
hitherto  connected  with  the  positive  pole,  and  vice,  versa. 
These  sudden  changes  produce  contractions  of  the  muscles, 


FIG.  166. — CURRENT  REVERSER. 

the  intensity  of  which  depends  on  the  strength  of  the  current 
and  the  sensitiveness  and  healthiness  of  the  muscle.  They 
are  therefore  very  important  for  diagnosis.  To  interrupt 
and  to  reverse  the  current  can  be  managed  with  a  single 
instrument,  of  which  we  give  a  diagram  (Fig.  166).  The 
negative  pole  of  the  battery  is  connected  with  R  and  N 


330        MANUAL  OF  PHYSIO  THERAPEUTICS 

the  positive  pole  with  the  metal  piece  between  these  two. 
While  the  cranks  point  towards  N  (normal),  as  in  the 
illustration,  the  right-hand  crank  is  connected  with  the 
negative  pole,  and  the  left-hand  crank  with  the  positive. 
By  moving  the  cranks  slightly  to  the  left,  so  that  they 
rest  on  E  and  N',  both  cranks  are  in  contact  with  the  negative 
pole:  consequently  there  is  no  current  at  all;  but  if  we 
move  the  cranks  farther,  so  that  they  point  towards  R, 
the  left-hand  crank  is  connected  with  the  negative  and  the 
right-hand  crank  with  the  positive  pole.  From  each  crank 
a  wire  leads  to  a  terminal  screw. 

Current  reversers  are  manufactured  in  many  shapes,  but 
in  principle  their  construction  is  always  the  same. 

8.  Two  terminals,  usually  at  the  side. 

9.  If  we  require  faradism,  a  sledge  coil  must  be  added. 

The  Galvanoset. 

This  is  a  patented  device  for  using  currents  from  the 
main  for  medical  purposes  by  an  exceedingly  simple  process. 
The  apparatus  is  a  potential  divider,  tap  water  replacing 
the  usual  metallic  resistance  wire.  The  water  is  contained 
in  a  heavy  glass  vessel  about  9  inches  in  diameter  and 
4  inches  deep.  Two  carbons  similar  to  those  used  with 
the  arc  lamp  dip  into  the  water  vertically,  and  are  placed 
as  far  apart  as  possible.  They  are  fixed  to  the  ebonite 
cover  of  the  vessel,  and  to  them  are  attached  the  patient's 
terminal  with  milliamperemeter  included  in  the  circuit. 
A  horizontally  rotating  arm  moves  around  a  central  vertical 
axis  just  below  the  cover,  and  carries  on  its  two  ends  vertical 
carbon  electrodes,  between  which  the  main  current  flows 
through  the  water. 

When  the  plane  of  the  two  movable  electrodes  is  at  right 
angles  to  the  plane  of  the  fixed  electrodes  the  potential 
at  the  patient's  terminal  is  zero,  whilst  when  turned  through 
90  degrees — i.e.,  when  the  plane  of  the  fixed  electrodes 
coincides  with  the  movable  electrodes — the  potential  is 
maximum.  Further,  when  the  planes  are  at  right  angles 
to  each  other  and  the  movable  electrodes  at  the  front  or 
at  the  end  of  the  bar  carrying  the  electrodes,  and  under  the 


THE  DYNAMO 


331 


sign  plus  is  made  the  positive  pole,  then  the  fixed  or  patient's 
terminal  towards  which  this  is  made  to  move  becomes  the 
positive  pole  of  the  patient. 

It  is  found  that  when  a  pressure  of  100  volts  is  applied 
between  the  fixed  electrodes,  a  maximum  current  of  about 
200  milliamperes  flows  in  the  derived  circuit.  It  compares 
very  favourably  with  an  ordinary  galvanic  battery,  both 


FIG.  167. — GALVANOSET,  WITH  F  ARABIC  COIL  ATTACHED. 

as  regards  expense,  wear  and  tear,  and  readiness  for  use; 
also  as  regards  its  range  of  adjustment  and  ease  of  keeping 
in  order.  The  weight  is  only  7  pounds,  and  the  whole 
apparatus  goes  into  a  light  portable  case. 

The  diagram  above  shows  very  clearly  the  electrical 
connections.  It  will  be  seen  that  the  current  from  the 
main  passes  through  a  switch,  and  then  to  a  lamp  on  to 
one  of  the  movable  electrodes,  thence  by  the  liquid  to  the 


332        MANUAL  OF  PHYSIO  THERAPEUTICS 

other  lamp,  and  so  to  the  other  pole  of  the  main.  The  supply 
terminals  are  mounted  on  an  insulated  bar  of  vulcanite, 
arranged  so  that  it  is  free  to  rotate  over  a  graduated  celluloid 


PIG.  168.     THE  PARADISET. 

scale.  If  this  disc  is  now  rotated  from  its  right  angle  or 
zero  position,  any  desired  current  can  be  obtained  from  a 
minimum  to  a  maximum  by  the  most  gradual  increase. 


PIG.  169.— SCHEME  OF  CIRCUIT  IN  GALVANOSET. 

If  it  is  desired  to  reverse  the  polarity  of  the  current  leading 
to  the  patient,  it  is  only  necessary  to  bring  the  bar  to  the 
zero  position  again,  and  to  continue  to  rotate  it  in  the 


opposite  direction.  By  moving  the  lever  backwards  and 
forwards  over  the  scale,  an  undulating  reversing  current  is 
obtained.  The  frequency  of  these  undulations  can  be 
increased  or  decreased  by  varying  the  speed  at  which  the 
lever  is  moved — a  thing  which  is  impossible  with  an  ordinary 
galvanic  battery.  By  it  one  can  give  a  galvanic  current 


FIG.  170.— GALVANOSET  IN  ACTION 


with  every  variation  from  0  to  500  milliamperes  at  any 
voltage  from  zero  to  the  maximum  required,  and  with 
absolute  safety  under  ordinary  circumstances.  There  is  a 
great  advantage  in  this  apparatus  over  a  switchboard 
utilizing  rheostats  of  nickel  wire,  as  the  wire  at  times  breaks 
and  causes  the  patient  a  shock.  Moreover,  the  surface  may 


334        MANUAL  OF  PHYSIO-THERAPEUTICS 

oxidize  and  cause  irregular  contact,  which  in  the  case  of  the 
galvanoset  cannot  happen.  With  a  wire  rheostat,  more- 
over, the  patient  is  always  connected  with  one  pole  of 
supply,  and  if  he  gets  into  contact  with  the  opposite  pole 
he  is  in  the  main  circuit.  A  recent  improvement  in  the 
galvanoset  is  making  the  positive  "  carbon  "  of  platinum, 
which  prevents  the  disintegration  which  sometimes  takes 
place  in  water,  producing  sediment  of  carbon  dust. 

Instructions  for  Using. — The  vulcanite  top  should  be 
removed  after  loosening  the  vulcanite  fixing  buttons,  and 
ordinary  tap  water  is  introduced  into  the  glass  vessel  to  the 
depth  of  3  inches.  The  vulcanite  top  is  then  fixed  on  again, 
and  resistance  lamps  introduced  to  their  sockets.  The 
scale-pointer  must  be  set  to  zero,  the  milliamperemeter 
properly  swung,  and  the  whole  apparatus  connected  with 
a  lamp-holder.  When  the  current  is  switched  on,  the  polarity 
must  be  first  ascertained 

The  lamps  will  glow  faintly  after  a  few  minutes,  but  not 
at  first.  To  determine  the  polarity  the  apparatus  con- 
nected to  the  lamp-holder  is  put  in  the  circuit.  After  a 
few  seconds  one  of  the  carbon  electrodes  will  be  observed 
giving  off  small  bubbles  of  gas  in  the  form  of  a  local  cloud — 
this  is  the  negative  pole.  A  smaller  quantity  of  larger 
bubbles  are  seen  on  the  positive  pole.  Alternatively,  pole- 
finding  paper  may  be  used.  If  the  carbon  at  the  back  of 
the  vessel  beneath  the  milliamperemeter  is  the  negative 
when  the  pointer  is  at  zero,  then  the  connection  is  correct. 
If  otherwise,  the  plug  must  be  removed,  given  a  half-turn, 
and  then  again  put  into  the  lamp-holder.  Hoth  polarity 
and  intensity  of  the  current  are  controlled  by  an  adjusting 
lever.  If  the  lever  is  moved  over  the  left-hand  half  of  the 
scale,  the  left-hand  patient  terminal  becomes  plus  ;  while 
if  the  lever  is  moved  over  the  right-hand  side  of  the  scale, 
the  right-hand  patient  terminal  becomes  plus,  and  vice 
versa.  A  peculiarity  of  this  machine  is  that  the  reversal 
of  the  polarity  causes  no  shock.  Voltage  and  milliamperage 
are  controlled  by  the  scale-pointer,  and  any  voltage  up  to 
80  can  be  obtained. 

The  apparatus  is  specially  well  adapted  for  use  with  a 
Schnee  four-cell  bath  (see  Fig.  170),  a  special  four-way 


THE  DYNAMO  335 

connection  being  used.  Currents  may  be  used  in  all  direc- 
tions and  for  any  set  of  cells  by  merely  adjusting  this  special 
switch. 

The  galvanoset  is  also  supplied  with  a  faradic  coil,  and 
in  order  to  utilize  this  the  milliamperemeter  is  removed  from 
its  stand  and  the  faradic  coil  hung  in  the  supporting  pillars 
in  place  of  it.  The  insulated  bar  provided  is  connected 
with  the  patient's  terminals.  The  contact-breaker  should 
be  inwards,  nearest  the  centre  of  the  apparatus.  These  are 
always  adjusted  before  being  sent  out,  but  the  ideal  adjust- 
ment is  to  have  the  hammer  about  tV  inch  away  from  the 
iron  core  which  attracts  it.  When  the  hammer  is  depressed, 
the  platinum  contact  on  the  spring  should  leave  the  platinum 
point  attached  to  the  platinum  screw  in  order  to  break  the 
current.  It  is  well  not  to  interfere  with  the  adjustment  of 
the  contact-breaker  once  it  is  put  in  order.  The  patient  is 


FIG.  171. — FOUR-WAY  CONNECTORS. 

now  connected  to  the  terminals  at  the  end  of  the  coil  by 
withdrawing  the  little  metal  sleeve,  situated  at  the  opposite 
end  of  the  coil,  on  which  the  contact-breaker  is  placed. 
The  intensity  of  the  current  entering  the  coil  will  be  governed 
by  the  position  of  the  galvanoset  lever.  Usually  this  has 
to  be  placed  at  about  No.  90  on  the  scale. 

Multiple  Treatment. — In  hospitals  several  patients  may 
be  treated  at  once  by  means  of  the  four- way  adapter 
(Fig.  171).  The  peg  projection  is  clamped  into  the  patient's 
terminals  at  either  side  of  the  galvanoset.  Any  number  of 
patients  up  to  four  can  then  be  treated  by  connecting  them 
to  the  four  sockets  on  either  side  of  the  instrument  that 
will  be  provided  by  this  means.  The  four-way  connectors 
are,  of  course,  used  for  the  four-cell  bath  also. 

The  Multostat. 

This  is  one  of  the  several  types  of  universal  apparatus. 
In  a  very  small  space  this  machine  contains  all  the  necessary 
controlling  and  regulating  fittings  for  galvanism,  sinusoidal 


336        MANUAL  OF  PHYSIO-THERAPEUTICS 

current,  faradism,  and  the  combined  current,  as  well  as 
cautery,  light,  and  motor  transformer.  The  whole  of  the 
apparatus  is  in  a  dust  proof  iron  case,  18  inches  by  18  inches, 
on  the  top  of  which  the  motor  transformer  is  fixed.  The 
case  is  heavy,  weighing  in  all  about  75  pounds,  but  a 
smoothly  running  table  on  castors  is  provided  for  its  easy 
transit. 

These  machines  can  be  made  to  suit  either  continuous  or 
alternating  mains.  The  current  consumed  is  so  small  that 
it  can  be  supplied  from  any  lamp-holder.  Perhaps  the 


FIG.  172.-  THE  MULTOSTAT  (PAXTOSTAT  FORM). 

most  striking  proof  of  the  adaptability  of  the  mechanism  is 
the  ease  with  which  it  can  be  used  for  the  cautery  or  light. 
In  the  case  of  a  direct  current  we  use  a  motor  trans- 
former to  convert  the  direct  current  into  an  alternating 
one,  which  is  passed  through  the  primary  of  a  small 
static  transformer,  the  secondary  of  which  is  so  arranged 
to  lower  the  voltage  to  the  required  level,  while  the  winding 
is  of  such  diameter  as  to  admit  of  the  use  of  the  heavy 
currents  required  for  light  or  cautery. 

The  current  consumption  is  very  low.  as  the  apparatus  can 
be  run  for  about  twopence  an  hour.     The  apparatus  is  also 


THE  DYNAMO  337 

entirely  earth-free  owing  to  the  use  of  the  motor  trans- 
former. 

A  milliamperemeter  is  provided  registering  up  to  500  milli- 
amperes,  which  permits  of  very  fine  work  being  done.  The 
speed  of  the  motor  can  be  nicely  adjusted,  as  is  necessary 
in  vibratory  treatment  and  the  working  of  the  sinusoidal. 
Apart  from  medical  uses,  of  course,  the  axle  of  the  motor 
can  be  put  to  various  very  handy  mechanical  purposes. 
If  the  supply  be  alternating,  special  adjustments  are  made 
with  a  repulsion  motor  coupled  to  a  direct-current  generator 
with  commutator  and  brushes,  the  latter  being  connected 
to  a  shunt  rheostat,  by  means  of  which  the  potential  is 
varied  from  zero  to  90  volts  or  thereby  on  the  patient's 
terminal.  The  current  for  the  primary  of  the  cautery  and 
light  transformer  in  the  case  is  taken  direct  from  the 
alternating  supply. 

If  there  be  no  direct  supply  from  the  main  to  the  house, 
the  multostat  can  be  run  from  a  battery  of  six  accumulators 
with  a  capacity  of  60  ampere-hours.  The  advantages  of 
such  a  multum  in  parvo  to  a  medical  man  are  obvious ;  there 
are  no  cells  to  get  out  of  order  if  the  main  current  is  available, 
neither  is  there  anything  to  repair.  The  apparatus  is  about 
as  "  fool-proof  "  as  can  well  be  imagined.  The  writer  has 
had  one  in  use  almost  daily  for  ten  years,  and  there  has  not 
been  the  slightest  breakdown  or  mishap,  and  it  works  just 
as  when  first  obtained.  Should  occasion  arise  at  any  time 
to  inspect  the  inner  working  of  the  machine,  the  bottom 
plate  is  taken  off  by  the  removal  of  a  few  screws. 

There  are  several  types  of  these  machines,  all  alike  in 
principle.  The  Polytherap,  an  American,  differs  in  that 
X  rays  can  be  generated  from  it  as  well.  We  may  briefly 
enumerate  the  advantages  as  follows: 

1.  Absolutely  true  galvanization  is  obtained. 

2.  No  chance  of  earth  leakage. 

3.  Inner  workings  closed  and  dust-free. 

4.  Freedom  from  breakdowns  and  absolute  reliability  in 
working. 

5.  Smoothness  in  regulating  current  of  any  type,  owing 
to  the  use  of  a  precision  type  of  turning  rheostat. 

6.  Specially  enclosed  motor  of  absolute  reliability. 


338         MANUAL  OF  PHYSIO-THERAPEUTICS 

7.  Can  be  built  for  direct  or  alternating  current. 

8.  A  very  clear  arrangement  of  switches,  rheostats,  and 
meters. 

9.  Great  ease  in  graduating  currents  by  rheostats  and 
regulating  motor  speed. 

10.  Compact    construction    and    ease    with    which    the 
machine  can  be  taken  from  one  room  to  another  in  an 
institution. 

11.  No  necessity  for  fixing  to  a  wall,  as  with  a  switch- 
board. 

Sinusoidal  Currents. 

The  word  "  sinusoidal  "  has  been  used  to  describe  a 
wave-like  alternating  current,  such  as  is  produced  by  an 
alternating-current  dynamo,  and  to  distinguish  it  from  the 
irregular,  jerky  alternating  current  produced  by  a  faradic 

Line  of  computation. 


Plane  of  the  coil. 


I 

FIG.  173. — CURVE  OF  A  SINUSOIDAL  CURRENT. 

coil.  When  a  copper  coil  rotates  with  uniform  velocity 
between  the  poles  of  an  electro-magnet,  the  current  collected 
is  sinusoidal — i.e.,  its  intensity  is  proportional  to  the  sine 
of  the  angle  between  the  plane  of  the  coil  and  the  line  of 
commutation. 


PIG.   174. — CURVE  OF  THE  SECONDARY  CURRENT  OF  A  FARADIC 

COIL. 

Figs.  173  and  174  respectively  show  the  curves  of  a  sinu- 
soidal current  and  the  more  jerky  movement  of  the  secon- 
dary current  of  a  faradic  coil.  The  latter  type  produces 
somewhat  painful  contractions  of  the  muscles,  whereas  the 


THE  DYNAMO 


339 


smooth  sinusoidal  currents  may  cause  equally  powerful 
contractions,  but  they  are  not  so  much  felt  by  the  patient. 
They  are  also  free  from  the  electrolytic  effects  produced  by 
a  continuous  current. 

We     distinguish    between    single-phase    and    polyphase 
sinusoidal    currents.      For    medical    purposes    three-phase 


FlG.   175. DIAGRAM  SHOWING  ARRANGEMENT  FOR  PRODUCING 

THREE-PHASE  CURRENTS. 

currents  are  frequently  employed,  and  to  obtain  them 
a  peculiar  connection  of  the  winding  of  the  armature  is 
necessary.  It  is  arranged  in  three  groups,  each  of  which 
occupies  one-third  of  the  circumference  of  the  armature. 
One  end  of  each  group  is  connected  with  one  of  the  three 
collecting  rings  shown  in  the  illustration  (Fig.  175),  and  the 


FIG.   170. 


FIG.   177. 


other  ends  are  connected  together.  While  the  first  group 
is  near  the  north  pole  of  the  dynamo,  the  second  is  120 
degrees  farther  ahead  (Fig.  176),  past  the  neutral  point, 
and  on  the  way  to  the  south  pole;  the  third  group  is 
240  degrees  ahead,  past  the  south  pole  already,  and  ap- 
proaching the  second  neutral  point.  Three  separate  waves 


340        MANUAL  OF  PHYSIO-THERAPEUTICS 

are  thus  generated,  and  are  interwoven  as  shown  in  Fig.  177, 
in  which  the  three  zigzag  lines  on  the  left  represent  the 
three  groups  of  wire  on  the  armature,  and  the  dotted  curves 
on  the  right  the  three  waves  of  current  in  the  external 
circuit  passing  through  the  primaries  of  the  three  sledge 
transformers. 

The  most  convenient  way  to  produce  sinusoidal  currents 
is  to  have  a  continuous-current  motor  provided  with  extra 
collector  rings,  from  which  the  sinusoidal  current  can  be 
taken  off.  If  it  has  two  rings,  single-phase  currents  only 
can  be  obtained;  if  it  has  three,  we  may  use  single  or  three- 
phase  currents.  In  the  first  instance  two,  and  in  the  second 
three,  electrodes  will  be  required  for  the  patient.  The 
three-phase  current  is  the  most  pleasant  sensation,  and  a 
fairly  powerful  current  can  be  employed  without  pain  or 
discomfort  to  the  patient. 


The  Herschell-Dean  Triphase  Generator. 

This  apparatus,  which  we  have  used  for  a  number  of 
years  with  satisfactory  results,  consists  of  a  field  armature 
with  a  commutator  having  equidistant  tappings  connected 
to  slip  rings,  on  which  brushes  are  held  in  contact  by  small 
springs.  The  triphase  currents  are  carried  by  flexible 
connecting  cords  to  the  primaries  of  three  induction  coils 
arranged  as  in  Fig.  178.  Instead  of  the  secondaries  moving, 
as  is  more  usual,  the  primaries  are  moved  by  means  of  a 
rack  and  pinion  adjustment,  preventing  jars  and  uneven- 
ness.  The  secondaries  of  the  coils  are  also  connected  up 
in  a  similar  manner  to  the  primaries.  The  current  is  led 
from  the  coils  to  the  electrodes  by  ordinary  flexible  cords 
which  are  attached  to  a  trident  plug,  which  simplifies  the 
manipulation  of  the  cords.  The  electrodes  being  in  intimate 
contact  with  the  skin,  the  circuit  is  formed  within  the 
organism.  The  E.M.F.  in  the  primary  is  controlled  by  a 
rheostat,  and  the  periodicity  by  a  break,  which  acts  by 
virtue  of  the  load  borne  by  the  generator,  and  reduces  the 
number  of  revolutions.  If  the  break  be  gradually  applied 
with  the  machine  running  at  full  speed,  a  progressive  reduc- 
tion in  revolutions  and  alternations  is  caused  without 


THE  DYNAMO 


341 


change  in  E.M.F.  of  the  currents.  The  machine  should 
never  be  suddenly  stopped  with  the  electrodes  in  contact 
with  the  patient,  or  he  will  receive  a  shock.  To  stop  the 
administration,  the  primaries  must  be  moved  back  to 
starting-point,  the  rheostat  be  put  at  "  weak,"  and  the 
current  switched  off.  The  electrodes  may  then  be  safely 
removed. 

Two    distinct    types   of   current   are    obtainable:    (1)    A 
rapidly    alternating     current,     with    powerful    action    on 


iii£»»»^««« 


FIG.  ITS. — TRIPHASE  APPARATUS  FOR  DIRECT  CURRENT  MAIM. 

metabolism  and  markedly  tonic  effect:  and  (2)  a  slowly 
alternating  current,  capable  of  especially  influencing  non- 
striped  muscle  tissue  and  causing  painless  contractions. 

The  trip  ha  se  current  may  be  applied — (1)  By  electrodes, 
large  flat  felt  or  sponge  electrodes  being  best  suited  for 
skin  surfaces.  Gastric  and  rectal  electrodes  are  also 
employed.  (2)  By  means  of  local  baths,  single  or 
multiple  (as  in  the  Schnee  bath).  (3)  By  a  general 
full  bath.  (4)  External  electrodes  may  be  combined 
with  baths. 

llerschell  found  an  application  uf  the  triprmse  currents 


342        MANUAL  OF  PHYSIO-THERAPEUTICS 

(1)  increases    the    tension   and   amplitude    of    the    pulse; 

(2)  increases  excretion  of  urea ;  (3)  increases  the  peristalsis 


FIG.  179.     POLYPHASE  SWITCHBOARD  WITH  MOTOK. 

of  the  intestines  and  contractions  of  stomach,  and  generally 
exerts  a  powerful  stimulant  action  on  non-striped  muscle. 
He  finds  these  currents  of  great  value  in  the  treatment  of 


THE  DYNAMO  343 

neurasthenia  and  gastric  myasthenia,  and  in  cases  of  con- 
stipation has  achieved  most  brilliant  results. 

Reginald  Morton  has  also  lately  drawn  attention  to  the 
great  value  of  triphase  sinusoidal  currents  in  atonic  con- 
ditions of  the  stomach  and  intestines.  An  intragastric 
may  be  combined  with  a  rectal  electrode,  and  an  external 
plate  or  pad  applied  to  the  epigastrium.  The  patient  may 
in  this  way  be  at  once  treated  for  gastrectasis,  and  the 
constipation  which  so  frequently  accompanies  it. 

The  sinusoidal  current  is  an  extremely  pleasant  and 
useful  application,  either  in  small  local  baths  or  the  full 
electric  bath.  It  resembles  the  faradic  current,  but  the 
interruptions  are  smoother  and  much  less  painful  to  the 
patient.  By  means  of  these  baths,  various  spastic  and 
other  paralyses  can  be  conveniently  treated.  The  current 
appears  to  lessen  the  late  rigidity  sometimes  seen  after 
hemiplegia. 


344       MANUAL  OF  PHYSIO-THERAPEUTICS 


The  Four-Cell  Bath. 

This  is  one  of  the  most  valuable  pieces  of  apparatus  in 
the  field  of  electro- therapeutics.  It  consists  of  a  strongly 
built  chair,  partly  oak  and  partly  iron,  fixed  to  the  ground 
preferably.  There  are  four  porcelain  pots  or  vessels,  two 
large  and  deep  for  the  feet,  and  two  longer  and  shallower 
for  the  hands  and  arms.  Into  a  slot  in  each  is  introduced 
a  fair-sized  carbon  electrode  connected  up  with  a  switch- 
board or  with  the  multostat.  The  multostat  is  preferable, 
as  it  is  quite  earth-free. 


FIG.  180. — SPECIAL  COMMUTATOR  FOB  A  FOUR-CELL  SCHNEE  BATH. 

Split  cords  connect  with  the  main  and  a  cleverly  devised 
commutator,  by  use  of  which  the  current  may  be  sent  in 
various  directions,  such  as  from  arm  to  arm  and  leg  to  leg, 
or  from  arm  to  leg,  right  or  left,  in,  as  the  inventor  claimed, 
fifty  different  ways.  We  cannot  claim  to  have  used  all 
fifty,  but  have  used  it  on  many  occasions  and  for  all  varieties 
of  disability. 

It  is  greatly  to  be  preferred  to  the  general  hydro-electric 
bath,  where  there  is  such  great  wastage  of  current.  A 
certain  amount,  indeed,  will  take  place  even  in  this  bath, 
but  it  is  materially  less. 

Every  type  of  current  may  be  used- — the  galvanic-far  a  die 
combined,  or  sinusoidal.  It  is  extremely  convenient  for 
ionic  treatment.  In  sciatica,  for  instance,  we  allow  the 


THE  DYNAMO  345 

patient  to  sit  on  a  large  pad  connected  with  the  negative 
pole  and  soaked  in  2  per  cent,  sodse  salicylate,  while  the 
foot  is  in  one  of  the  pots  connected  with  the  positive  pole. 
Arms  and  hands  may  be  treated  similarly,  mutatis  mutandis. 
The  intensity  of  the  current  is  capable  of  being  regulated 
and  measured  with  considerable  exactitude.  The  patient 


FIG.  181. — THE  SCHNEE  FOUR-CELL  BATH. 

need  only  partially  undress,  divesting  himself  of  shoes  and 
socks  and  his  coat  and  vest  at  most.  Many  people  find  the 
erect  posture  preferable;  the  arms  are  supported  and  in  a 
comfortable  position,  and  the  whole  chair  is  capable  of 
considerable  adjustment. 

The  strength  of  current  employed  will  vary  very  greatly 
with  different  patients  and  different  affections.     In  ionizing 


346        MANUAL  OF  PHYSIO-THERAPEUTICS 

a  sciatica  we  may  rise  to  50  milliamperes  or  more  for  thirty 
to  forty  minutes. 

As  a  general  tonic  measure  we  use  either  the  combined 
galvano-faradic    current    or    the    sinusoidal;    the  latter  is 


perhaps  the  more  pleasant,  and  there  is  not  the  same  ten- 
dency to  irritation  around  the  skin  at  the  surface  of  the 
water  as  is  the  case  with  galvanism.  A  red  line  is  usually 
found  after  a  treatment  lasting  any  time.  Glycerine  or 
liquid  paraffin  poured  on  the  surface  tends  to  prevent  this. 
Patients  must  be  warned  not  to  attempt  to  stop  the  bath 


THE  DYNAMO  347 

by  withdrawing  hands  or  feet  if  the  current  seems  too 
strong.  The  attendant  has  to  stand  by,  and  the  current, 
of  whatever  kind,  must  be  gradually  turned  off  by  adding 
resistance  with  the  galvanic,  or  withdrawing  the  primary 
with  the  faradic,  or  moving  back  the  secondary  with  the 
sinusoidal,  or  slowing  the  motor  if  we  are  using  a  multostat. 
Sudden  withdrawal  may  cause  a  severe  shock,  so  unpleasant 
as  to  "  put  the  patient  against  the  treatment  "  for  a  con- 
siderable time,  if  not  permanently. 


The  General  Hydro-Electric  Bath. 

This  is  still  described  in  some  of  the  textbooks,  but  we 
consider  it  is  a  form  of  treatment  which  might  with  propriety 
be  abandoned.  Some  authorities  have  estimated  the 
amount  of  current  which  passes  through  the  patient's  body 
as  one-eighth  of  that  which  passes  through  the  water  itself. 
Wilfred  Harris  puts  it  as  high  as  1  in  3,  but  even  he  points 
out  that  to  send  a  current  of  50  milliamperes  through  a 
patient  we  shall  require  to  keep  one  going  of  at  least 
150  milliamperes. 

There  is  thus  great  wastage,  and  as  it  is  well  known  that 
the  ohmic  resistance  of  the  human  body  varies  very  greatly 
with  the  individual,  we  can  really  have  very  little  idea  of 
what  the  patient  is  getting  at  any  time.  A  further  serious 
drawback  to  this  type  of  bath  is  that  during  the  whole  time 
the  current  is  going  the  patient  is  immersed  in  warm  water, 
which  rather  undoes  the  tonic  effect  of  the  bath  by  its 
enervating  influence.  If  it  is  allowed  to  cool  again,  he  is 
liable  to  get  a  chill. 

We  can  certainly  recall  cases  that  improved  with  the 
bath,  but  taking  the  current  wastage  and  indefiniteness  of  the 
dose  along  with  the  very  real  risk  of  earth  currents  and 
shocks  by  which  a  number  of  people  have  been  killed,  we 
think  the  bath  may  be  quite  well  relegated  to  the  scrap- 
heap,  and  the  much  superior  four-cell  arrangement  be 
employed. 


X  RAYS  AND  THEIR  PRODUCTION 

THE  discovery  of  X  rays  by  Roentgen  in  1895  has  been 
mentioned  above  in  connection  with  the  periods  of  electrical 
development. 

Radiography  hardly  comes  within  the  range  of  physio- 
therapy, being  largely  diagnostic  in  character.  We  are  only 
concerned  with  it  in  so  far  as  radio-therapy  is  concerned, 
and  that  in  itself  has  become  so  highly  specialized  a  subject 
as  to  be  almost  beyond  the  range  of  this  volume. 

At  the  same  time,  the  outfit  required  for  electro-thera- 
peutics is  so  interconnected  with  other  treatment,  such  as 
high-frequency,  that  it  is  essential  that  anyone  working  at 
electro-therapeutics  has  a  sound  grasp  of  what,  for  instance, 
is  meant  by  an  X-ray  installation. 

It  is  therefore  incumbent  upon  us  to  describe  without 
any  unnecessary  elaboration  the  basic  elements  of  an  X-ray 
equipment. 

What  are  X  rays  ?  They  are  radiations  propagated  with 
the  velocity  of  light  and  the  Hertzian  waves  with  a  wave- 
length much  shorter  than  the  ultra-violet  rays.  There  is 
a  graduated  scale  for  them,  just  as  there  is  a  scale  for 
luminous  rays  for  the  spectrum.  Roentgen  during  the 
course  of  his  researches  for  the  invisible  light  rays  turned 
on  the  low-pressure  discharge  tube  which  he  had  enclosed 
in  stout  black  paper.  Greatly  to  his  surprise,  a  fluorescent 
screen  which  he  had  some  9  feet  away  shone  out  brightly. 
The  light-tight  black  paper  precluded  this  being  due  to 
ultra-violet  rays — plainly  it  was  due  to  some  other  type. 
He  found  that  interposed  obstacles  or  objects  cast  shadows 
on  the  screen,  and  so  (faced  back  the  rays,  which  he  called 
X  rays  for  want  of  a  better  name,  to  their  source.  They 


X  RAYS  AND  THEIR  PRODUCTION  349 

emanated  from  the  region  of  impact  of  the  kathodal  rays 
on  the  glass  walls  of  the  tube. 

Like  many  other  wonderful  things  in  medicine  and  science, 
X  rays  have  a  composite  origin.  Crookes  invented  the 
Crookes  tube,  of  which  the  modern  X-ray  tube  is  but  an  elab- 
oration. What  is  a  Crookes  tube  ?  It  is  a  glass  6  inches  in  dia- 
meter with  platinum  wire  electrodes  fused  into  the  opposite 
walls  of  it,  so  that  the  wire  projects  into  the  tube,  leaving  a 
space  about  3  inches  between  the  two  ends.  A  nozzle  in 
the  side  of  the  tube  is  made  and  connected  with  the  air 
pump,  so  as  to  enable  us  to  exhaust  the  air.  If  we  now 
connect  one  wire  outside  with  the  anode  of  a  12-inch  coil 
and  the  other  with  the  kathode,  we  can  observe  the  changes 
in  the  character  of  the  discharge  as  the  tube  is  exhausted 
by  the  air  pump. 

In  the  first  place,  if  we  have  not  pumped  out  any  air, 
the  discharge  is  precisely  similar  to  what  takes  place  between 
the  anode  and  the  kathode  across  the  air  gap  of  any  coil, 
the  resistance  offered  being  practically  the  same.  If  we 
set  the  pump  working  and  reduce  the  air  to  ToW  of  an 
atmosphere,  we  make  what  is  called  a  Geissler  tube.  The 
resistance  between  the  terminals  is  now  greatly  reduced; 
we  observe  no  sparks  or  noise  in  the  discharge,  but  a  beauti- 
ful stream  of  blue  light  stretching  from  the  kathode  to  the 
anode.  Every  student  of  physics  has  seen  the  experiment 
done  long  before  X  rays  were  known.  The  stream  may 
be  deflected  by  the  demonstrator's  finger,  causing  the  glass 
at  the  side  on  which  it  impinges  to  fluoresce.  The  stream 
of  blue  light  is  called  a  kathodal  beam,  and  is  of  the  nature 
of  fluorescence  excited  in  the  rarefied  air  by  the  passage 
of  an  invisible  stream  of  particles  from  the  kathode  to  the 
antikathode,  known  as  the  kathodal  rays.  The  particles 
constituting  them  are  probably  atoms  of  hydrogen  gas 
travelling  from  pole  to  pole  at  the  almost  inconceivable 
velocity  of  20,000  to  50,000  miles  per  second.  The  kathodal 
stream  consists  of  negatively  electrified  electrons,  probably 
less  than  ,  oW  of  the  bulk  of  the  hydrogen  atom,  the  smallest 
chemical  weight  known.  The  beam  differs  from  the  X  rays 
in  that  the  latter  cannot  be  diverted  from  their  course  by 
a  magnet  and  do  not  consist  of  electrons.  They  are  rather 


350        MANUAL  OF  PHYSIO-THERAPEUTICS 

a  special  form  of  pulsating  vibrations  in  ether  set  up  by 
the  impact  of  the  beam  of  electrons  in  the  kathodal  rays 
upon  the  object  which  they  strike — e.g.,  the  side  of  tube 
or  antikathode.  X  rays  are  also  quite  invisible  and  cannot 
be  polarized. 

Kathodal  rays  form  the  whole  basis  of  X  rays,  the  whole 
theory  of  which  revolves  around  them.  We  turn  a  glass 
bulb  into  a  Geissler  tube  and  then  into  a  Crookes  tube  by 
further  exhaustion  until  we  have  produced  a  vacuum  of 
less  than  T7roinnro  part  of  an  atmosphere — a  veiy  high 
vacuum  indeed. 

In  doing  so,  after  first  reducing  the  resistance  of  the  tube 
to  the  passage  of  the  current,  we  actually  raise  it  until  it 
is  much  greater  than  when  the  tube  was  full  of  air.  The 
degree  of  resistance  which  exists  is  estimated  by  the  use  of 
what  is  known  as  an  equivalent  spark  gap.  We  connect 
an  X-ray  tube  in  parallel  with  a  variable  spark  gap,  and 
note  the  length  of  the  gap  when  the  spark,  so  to  speak, 
prefers  to  jump  across  it  rather  than  take  the  line  of  the 
tube ;  at  that  point  we  have  the  equivalent  spark  length  of 
the  tube  and  a  definite  measure  of  the  resistance  to  the 
passage  of  the  current.  A  tube  exhausted  to  TOOOUOO  of 
an  atmosphere  has  a  resistance  equal  to  a  2-inch  spark  gap 
approximately.  By  further  exhaustion  we  can  run  up  to 
an  8-inch  spark  gap,  the  limit  being  reached  with  complete 
vacuum  when  no  current  passes  whatever.  The  explana- 
tion of  this  is  a  very  technical  matter,  rather  in  the  range 
of  pure  physics  than  in  practical  X-ray  work,  and  does  not, 
therefore,  particularly  concern  us,  but  on  a  clear  percep- 
tion of  the  underlying  principle  will  depend  our  proper 
understanding  of  what  are  called  soft  and  hard  tubes, 
and  so  on. 

When  the  current  is  passing  through  a  Crookes  tube  from 
simple  wire  electrodes  very  little  is  seen — kathodal  rays 
are  there  in  plenty,  but  are  quite  imperceptible;  they  pass 
to  the  inner  surface  of  the  tube,  and  there  originate  the 
X  rays,  which  are  again  invisible,  as  stated  above.  What 
we  do  see  is  the  greenish  fluorescence  of  the  tube  where  the 
kathodal  stream  strikes  the  glass.  A  certain  amount  of 
heat  is  produced  as  well  by  the  kathodal  rays,  and  if  they 


X  RAYS  AND  THEIR  PRODUCTION 


351 


are  focussed  in  any  way  the  heat  may  melt  the  glass.  Their 
impact  is  the  cause  of  the  generation  of  X  rays,  whether  they 
strike  the  tube  walls  or  the  antikathode.  The  greater  the 
vacuum,  the  greater  the  velocity  of  the  kathodal  rays  and 
the  more  penetrating  the  X  rays  produced. 

The  kathodal  rays  are  focussed  on  the  antikathode  by 
putting  a  small  concave  aluminium  disc  on  the  end  of 
the  kathode,  and  this  is  the  embryo  or  basis  of  the 
focus  tube. 

The  Production  of  X  Rays. 

We  must  submit  the  following  postulates:  (1)  A  supply 
of  electricity;  (2)  some  means  of  transforming  the  current 
to  a  high  intensity,  such  as  the  step-up  transformer; 
(3)  an  X-ray  or  focus  tube. 

We  may  add  many  elaborations  for  photographic  work, 
but  little  more  is  needed  for  radio-therapy.  Certain 
accessory  apparatus  is,  however,  needed  to  render  the 
current  for  the  tube  suitable  for  the  purpose,  and  to 
regulate  the  quantity. 

As  stated  elsewhere,  in  most  large  cities  the  current  is 


200  Volt  D.  C. 


Iron  Core 


01 

1      1 

\  Condenser  for  / 
\  Lei/dan  Jars  / 
Ccuch  for  r-^-isnt 

FIG.  183. — DIAGRAMMATIC  SCHEME  OF  X-RAY  APPARATUS. 


high  voltage  and  alternating  in  character,  requiring  trans- 
forming at  substations.  For  a  private  supply  we  can 
generate  by  an  ordinary  gas-engine  plant,  which  can  be 


352        MANUAL  OF  PHYSIO-THERAPEUTICS 

used  to  drive  a  dynamo  of  1|  to  2  horse-power  with  a 
mercury  break,  or  one  of  3  to  4  horse-power  with  an  electro- 
lytic break. 

It  is  desirable  to  have  a  battery  of  secondary  storage 
cells,  and  one  of  twenty-seven  cells  of  75  ampere-hours 
will  suffice;  this  will  require  charging  up  every  week  or 
ten  days. 

The  X-Ray  Outfit. 

A  very  compact  and  excellent  type  of  X-ray  apparatus 
is  figured  below.  It  is  one  very  largely  in  use  at  the  present 


FIG    184 -COMPLETE  X-IlAY  APPARATUS. 

time.  The  apparatus  is  so  mounted  and  the  high-tension 
wires  so  arranged  that  accidental  shocks  to  the  patient  or 
operator  are  extremely  unlikely  or  impossible. 


X  RAYS  AND  THEIR  PRODUCTION  363 

From  the  top  of  the  discharging  pillars  or  the  spark  gap 
two  aluminium  rods  about  2  feet  in  length  project,  ter- 
minating in  two  spring  rheophores,  each  containing  72  inches 
of  metallic  flexible  conductor,  which  is  carried  to  the  X-ray 
tube  itself.  Slight  tension  is  always  kept  up  in  this  by 
means  of  springs,  the  tension  applied  keeping  them  apart 
and  taut,  thus  reducing  the  risk  of  sparking  to  the  patient 
or  apparatus  to  a  minimum.  The  operator  can  also  work 
on  either  side  of  his  patient  or  switchboard  without  coming 
into  contact  with  the  wires. 

The  parts  of  the  apparatus  are  as  follows: 

1.  The  switchboard  fitted  with  a  double-pole  main  switch, 
double-pole  fuses  and  pilot's  lamps,  amperemeter,  rheostat 
for  motor  and  transformer,  and  main  supply  terminals. 

2.  The  coil  of  Rochefort-Gaiffe  type,  sectional  wound. 

3.  Interrupter  of  gas-mercury  type  (autonome). 

4.  The    spintermeter,    controlled    by    rack    and     pinion 
adjustment. 

6.  Valve  tubes  are  of  Pilon  type,  with  supports  of  red 
fibre. 

6.  Milliamperemeter  of  the  dead-heat  d'Arsonval  type, 
with  a  protective  condenser  to  prevent  injury  from  internal 
sparking. 

The  X-Ray  Coil. — One  might  describe  the  X-ray  coil  as  the 
backbone  of  an  X-ray  outfit.  If  a  doctor  tells  us  he  is 
doing  radiography,  the  first  question  that  suggests  itself 
is,  What  sort  of  coil  have  you  got  —  12-inch,  16-inch,  or 
18-inch  ? 

The  X-ray  coil  is  really  but  an  elaboration  of  the  Rhum- 
korff  coil  of  our  physics  days  (fully  described  under 
Faradism),  but  it  is  much  more  powerful  with  a  very  much 
longer  secondary  winding.  It  may  run  to  a  mile  or  con- 
siderably more  of  fine  wire.  Briefly,  the  essential  parts 
are — 

(1)  The  primary  coil,  which  consists  of  a  number  of  thin 
rods  of  iron,  round  which  are  passed  numerous  turns  of 
copper  wire.     This  is  insulated  from  the  secondary  coil  by 
being  placed  inside  a  vulcanite  tube. 

(2)  The  secondary  coil  is  much  more  elaborate,  and  con- 
sists of  a  very  great  number  of  turns  of  fine  copper  wire 

23 


354        MANUAL  OF  PHYSIO-THERAPEUTICS 

wound  in  a  number  of  sections  vertical  to  the  plane  of  the 
coil. 

The  E.M.F.  or  spark  gap  to  be  obtained  increases  with 
the  number  of  turns  used,  or,  in  other  words,  with  the  length 
of  the  secondary  coil.  Thus  we  can  transform  a  primary 
current  of  200  volts  to  50,000  or  even  100,000,  but  the 
number  of  amperes  is  reduced  in  the  same  proportion.  The 
amount  of  energy  is  never  increased,  as  this  would  be 
contrary  to  a  physical  law;  and  not  only  so,  but,  on  the 
contrary,  a  certain  amount  of  loss  is  incurred  in  the  trans- 
formation from,  one  potential  to  another. 


FIG.  185. — ETJHMKOKFF  INDUCTION  COIL,  SHOWN 
DlAGRAMMATICAIXY.     (WILLIAMS.) 

The  Condenser,  a  very  important  part  of  the  coil,  lies 
usually  in  its  base ;  it  is  absolutely  necessary  when  a  mercury 
break  is  being  used.  It  is  connected  in  parallel  with  the 
interrupter,  and  helps  to  reduce  the  spark  appearing  in  the 
interrupter  on  breaking  the  primary,  and  also  tends  to 
demagnetize  the  core  rapidly.  It  is  not  called  for  if  a 
Wehnelt  break  be  used. 

The  condenser  consists  of  a  number  of  sheets  of  tin-foil 
insulated  from  one  another  by  sheets  of  waxed  paper. 

The  above  diagram  will  give  a  rough  idea  of  the  working 
of  the  coil  condenser,  etc.  The  current  passes  from  the 
positive  pole  of  the  battery  or  the  main  by  TX  to  d,  the 
adjusting  screw,  and  thence  through  the  platinum  con- 


X  RAYS  AND  THEIR  PRODUCTION  355 

tacts  6  and  the  primary  winding  P  back  to  the  negative 
pole  T.2.  The  circuit  is  completed,  and  the  core  T  be- 
comes magnetized,  the  hammer  H  is  attracted,  and  the 
platinum  contacts  pulled  apart,  thus  breaking  the  circuit. 
All  this  is  familiar  to  those  who  recall  the  physiological 
physics. 

The  core  then  becomes  demagnetized,  and  the  platinum 
contacts  are  pulled  together  again  by  means  of  the  brass 
spring,  contact  being  made ;  the  iron  core  is  again  magnetized, 
and  so  on  ad  infinitum.  G  represents  the  condenser,  with 
the  thick  lines  representing  waxed  paper  and  the  thin  ones 
tin-foil.  When  the  contact  at  B  is  broken,  the  current 
passes  into  the  condenser,  and  tends  to  hasten  the  de- 
magnetization of  the  core. 

The  E.M.F.  of  a  coil  or  the  spark  length  depends  to  a 
great  extent  on  the  number  of  secondary  windings.  Every 
coil  is  provided  with  sparking  pillars,  one  being  a  point 
and  the  other  plate-like  in  form.  The  object  of  these  is 
the  detection  of  polarity.  When  the  plate  is  the  negative 
pole,  sparks  discharge  easily  to  any  part  of  the  plate;  when 
the  point  is  negative,  on  the  other  hand,  sparks  will  dis- 
charge to  the  point  from  the  edge  of  the  plate.  The  passing 
of  the  current  through  the  primary  coil  sets  up  a  magnetic 
field,  and  this,  as  well  as  its  disappearance,  induces  currents 
of  short  duration  in  the  secondary  coil,  their  strength 
depending  on  the  intensity  of  the  magnetic  field  and  the 
suddenness  of  its  appearance  or  disappearance. 

With  regard  to  coils,  a  very  important  point  to  remember 
is  that  for  radiography,  and  specially  for  instantaneous 
work,  powerful  coils  of  18  to  22  inches  are  required,  but 
for  therapeutic  work,  with  which  we  are  here  alone  con- 
cerned, smaller  coils  of  10  to  12  inches  suffice  admirably. 

The  Switchboard. — The  coil  is  controlled  from  the  switch- 
board. This  is  usually  fixed  to  the  wall  of  the  room  or  on 
a  special  stand,  and  is  of  black  slate  or  marble.  It  is 
provided  with  all  the  necessary  switches,  fuses,  and  ter- 
minals, and  a  signal  lamp  to  show  when  the  current  is  on. 
There  is  a  switch  and  rheostat  to  control  the  speed  of  the 
interrupter,  and  an  ammeter  by  which  to  record  the  primary 
current. 


356        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  X-Ray  Tube. — The  X-ray  tube  is,  after  the  coil,  the 
most  important  element  in  the  equipment  for  X-ray  work. 
Initially  consisting  of  a  glass  sphere,  the  X-ray  tube  has 
become  somewhat  more  complicated  from  the  addition  of 
various  horns  or  windows  for  one  purpose  or  another.  In 
the  manufacture  the  electrodes  and  terminals  have  to  be 
placed  in  position,  the  tube  exhausted  and  annealed.  Great 
care  is  needed  in  this  process,  and  much  time  often  expended. 

The  various  parts  of  the  tubes  are  depicted  in  Fig.  186. 
The  antikathode  calls  for  much  care  and  consideration.  In 
the  better  type  of  tube  it  is  a  very  solid,  heavy  one,  made 
of  copper  or  nickel  fitted  with  platinum,  and  for  very  heavy 
work  tungsten.  The  capacity  of  the  tube  to  stand  a  heavy 
current  depends  largely  on  the  weight  of  metal  used.  There 
is  a  great  tendency  for  the  antikathode  to  get  hot  during 
the  running  of  the  tube,  especially  if  a  heavy  current  be 
used,  and  this  is  combated  by  various  devices.  One  is  the 
Cyclops  tube,  in  which  the  copper  portion  of  the  antikathode 
can  be  exchanged  by  withdrawal  during  the  time  the  tube 
is  in  use.  The  other  and  more  commonly  employed  is  the 
water-cooled  tube,  in  which  the  back  of  the  target  is  practi- 
cally immersed  in  water,  for  which  there  is  a  special  extension 
blown. 

Such  tubes  may  be  used  for  hours  without  getting  heated, 
and  so  "  softened." 

In  connecting  up  the  tube  it  has  to  be  remembered  always, 
as  mentioned  elsewhere,  that  the  kathode  or  concave 
aluminium  terminal  is  connected  with  the  negative  pole 
of  the  coil,  and  the  antikathode  with  the  positive.  Neglect 
of  this  precaution  will  damage  the  tube  and  make  good  work 
impossible. 

Hard  and  Soft  Tubes. — Heating  of  the  target  and  pro- 
longed use  of  a  tube  tends  to  make  it  soft,  as  it  is  called. 
That  is,  the  vacuum  is  lessened  and  the  tendency  to  burns 
is  greatly  increased.  Gases  are  released  from  the  glass  and 
the  vacuum  so  reduced.  Rest  and  cooling  of  the  tube  will 
so  far  remedy  this,  but  failing  that  a  small  current  of,  say, 
-|  to  5  milliamperes  should  be  passed  for  a  quarter  to  half 
an  hour  until  the  required  vacuum  is  attained.  On  the 
other  hand,  if  the  tube  is  hard  the  vacuum  may  be  lowered 


X  RAYS  AND  THEIR  PRODUCTION  357 

by  running  the  current  the  normal  way  for  ten  minutes  or 
so,  or  by  use  of  the  device  known  as  an  osmo-regulator,  a 
small  palladium  tube  projected  through  the  neck  of  the 
bulb.  This  metal  has  the  curious  faculty  of  allowing 
hydrogen  to  pass  through  it  while  it  is  hot  by  a  process 
known  as  osmosis.  Therefore,  if  it  is  made  incandescent 
by  means  of  a  match  or  spirit-lamp,  the  vacuum  can  be 
reduced  by  means  of  hydrogen  gas.  Before  using  the 


NO  14 


FIG.  186. — -CHART  OF  AN  X-RAY  TUBE. 

1,  Antika^hode  or  anode  surface;  2,  kathode  surface;  3,  anode  or 
accessory  anode  surface;  4,  sealing-in  point  and  cap  of  anti- 
kathode;  5,  sealing-in  point  and  cap  of  kathode;  6,  sealing-in 
point  and  cap  of  anode;  7,  hemisphere  of  X  ray;  8,  heightening 
device  on  regulator  or  auxiliary  antikathode ;  9,  lowering  device 
on  regulator  or  auxiliary  kathode;  10,  movable  swivel  on  regu- 
lator; 11,  wall  between  universal  regulating  device;  12,  connec- 
tion between  main  bulb  to  regulating  device;  13,  glass  rod  back 
of  antikathode;  14,  glass  rod  back  of  kathode;  15,  wire  between 
antikathode  and  anode;  16,  exhaust  tip. 

X-ray  tube  again  the  osmo-regulator  must  be  allowed  to 
completely  cool. 

Another  form  of  regulator  is  the  mica  type,  in  which 
some  mica  or  carbon  having  the  capacity  for  releasing  gases 
is  kept  in  a  small  sealed  cylinder  communicating  with  the 
tube.  By  means  of  special  terminals  for  regulating,  current 
can  be  passed  through  this  and  the  mica  heated. 

The  rays  of  soft  tubes  are  of  low  penetrative  power,  and 


358        MANUAL  OF  PHYSIO-THERAPEUTICS 


the  tube  does  not  require  a  very  high  E.M.F.  to  work  it. 
Hard  tubes,  on  the  other  hand,  require  very  high  E.M.F., 


being  very  resistive  to  currents  passing  through,  and  the 
rays  are  highly  penetrative.  With  the  harder  types  of  tube 
even  bone  becomes  transparent. 


X  BAYS  AND  THEIR  PRODUCTION  359 

All  these  points  are  of  more  or  less  photographic  or 
radiographic  than  therapeutic  interest,  but  must  be  grasped 
to  comprehend  the  working  of  an  X-ray  outfit. 

The  operator  requires  to  remember  that  it  is  of  the 
greatest  importance  to  connect  the  tube  properly  with  the 
induction  coil,  or  its  life  will  be  short.  The  antikathode 
has  two  functions — (1)  it  is  the  active  anode  of  the  tube 
as  well  as  (2)  the  target  which  the  stream  strikes.  It  must 
be  always  connected  with  the  positive  pole  of  the  coil. 
Similarly,  the  kathode  requires  to  be  always  connected  with 
the  negative  pole.  This  having  been  done  and  the  current 
switched  on,  the  current  enters  the  tube,  leaving  at  the 
kathode. 

The  kathodal  stream  initiated  on  the  concave  aluminium 
surface  of  the  kathode  is  then  discharged  with  tremendous 
velocity,  as  above  mentioned,  and  brought  to  a  focus  near 
the  centre  of  the  antikathode.  Here  the  X  rays  are 
generated  and  discharged  in  all  directions  after  the  manner 
of  the  ribs  of  a  fan.  Though  they  are  themselves  invisible, 
they  yet  cause  a  very  marked  fluorescence  which  lights  up 
the  whole  of  the  tube  in  front  of  the  antikathode.  A  sharp 
plane  of  differentiation  between  the  light  and  dark  zone 
(behind  the  antikathode)  is  at  once  noticeable.  Irregularity 
in  this  respect  is  due  to  the  wroi  g  connection,  or  what  is 
called  reverse  current. 

If  the  former,  the  current  must  be  switched  off  and 
reconnection  made  properly.  If  the  latter,  it  is  less  easy 
of  remedy,  but  the  proper  course  of  action  will  be  described 
later.  Perfection  is  not  always  reached  without  practice, 
needless  to  say. 

Any  change  will  at  once  be  noticed,  for  the  vacuum  falls 
so  as  to  make  the  tube  uselessly  soft;  therewith  a  display 
a  purple  or  violet  fluorescence  which  will  cease  altogether 
when  the  tube  acts  as  a  spark  gap.  If  the  vacuum  becomes 
higher  the  characteristic  fluorescence  is  yellow  more  than 
green,  and  with  very  high  vacuum  no  current  will  pass  at 
all;  fluorescence  again  ceases,  and  sparking  all  over  will 
take  place.  The  storing  of  tubes  requires  some  care,  as 
they  are  not  very  easy  things  to  handle  and  put  away. 
They  should  be  under  cover  of  some  sort  to  keep  the  dust 


360        MANUAL  OF  PHYSIO-THERAPEUTICS 

away,  or  kept  on  perforated  shelves  with  the  holes  padded 
and  large  enough  to  pass  the  kathode  stem  through.  If 
a  number  are  in  use,  it  will  be  convenient  to  have  shelves 
for  the  three  grades — hard,  soft,  and  medium. 

It  has  been  pointed  out  that  every  tube  has  its  appro- 
priate current:  what  Schall  calls  the  normal  current  for  it. 
It  may  be  defined  as  the  amount  of  current  that  will  keep 
the  degree  of  vacuum  constant.  This  is  done  by  only  as 
much  gas  being  liberated  from  the  antikathode  as  can  be 
taken  up  by  the  tube  walls.  The  operator  is  kept  right  so 
far  in  regard  to  this  if  he  always  has,  as  he  should  have, 
a  milliamperemeter  in  the  tube  circuit. 

If  we  start  off,  say,  with  1  milliampere  passing  and  sudden 
rise  occurs,  the  resistance  has  plainly  been  lowered  from 
some  cause,  and  the  current  must  be  reduced  or  cut  off. 
If  the  indicator  falls,  then  the  resistance  must  be  rising, 
and  the  vacuum  should  be  reduced.  With  a  new  tube  it  is 
quite  enough  to  start  with  a  \  milliampere  current  and 
gradually  raise  it  to  3,  which  will  quite  suffice  for  all  thera- 
peutic purposes.  The  tube  requires  a  certain  amount  of 
seasoning  always.  In  instantaneous  photography  of  the 
lungs  or  heart,  of  course,  it  is  customary  to  send  a  very 
heavy  current  through,  with  as  much  as  50  or  100  milli- 
amperes  for  ^V  of  a  second.  While  tubes  do  burst  at  times 
under  this  strain,  it  is  less  likely  to  do  harm  than  a  current 
of  10  or  15  milliamperes  for  a  few  seconds. 

The  range  of  current  we  can  use  depends  largely  on  the 
tubes  employed,  but  it  varies  from  2  to  5  milliamperes. 
We  seldom  exceed  3  milliamperes,  however,  and  for  a  small 
tube  0-5  is  ample. 

The  lifetime  of  an  X-ray  tube  depends  on  a  variety  of 
factors,  but  none  of  them  last  indefinitely.  The  tendency 
is  for  a  tube  to  become  hard — in  other  words,  for  the  vacuum 
to  be  so  complete  that  it  is  next  to  impossible  to  send  a 
current  through  it. 

The  terms  hard,  soft,  and  medium,  are  regularly  used 
in  describing  tubes,  and  they  at  once  indicate  the  degree 
of  exhaustion  of  the  tube,  the  resistance  opposed  to  the 
passage  of  the  current,  and  the  degree  of  penetrating  power 
of  the  X  rays  produced. 


X  RAYS  AND  THEIR  PRODUCTION  361 

It  has  been  suggested  that  as  a  tube  is  used  its  vacuum 
becomes  higher,  owing  to  particles  of  gas  being  forced  into 
the  glass  as  a  result  of  the  tremendous  velocity  at  which 
the  hydrogen  electrons  travel.  This  is,  of  course,  a  matter 
difficult  of  proof,  and  is  largely  pure  theory. 

Back  electro-motive  force  or  reverse  currents  tend  to 
shorten  the  life  of  a  tube,  as  small  particles  of  platinum  are 
torn  off  the  antikathode,  and  these  absorb  gas  in  the  tube. 
This  is  why  we  have  to  be  very  careful  to  watch  the  con- 
necting up  of  the  tube  at  the  start,  as  a  few  minutes  with 
the  current  going  the  wrong  way  will  spoil  a  tube. 

Overuse  of  a  new  tube,  which  is  usually  soft,  will  spoil  it, 
as  it  will  make  it  more  soft  still,  and  the  rays  are  then  of 
such  low  penetrative  power  as  to  be  useless.  A  heavy 
current  passed  through  a  tube  will  very  soon  heat  the  anti- 
kathode,  and  even  melt  it,  and  this,  of  course,  finishes  the 
useful  career  of  the  tube.  This  can  be  guarded  against 
by  noting  when  the  antikathode  gets  red,  and  then  cooling 
off  by  stopping  the  current.  Occasionally  perforation  of 
a  tube  will  spoil  it,  and  this,  it  may  be  said,  is  an  accident 
which  will  happen  "in  the  best  regulated  families."  It  is 
more  common  in  a  hard  tube  than  a  soft,  and  may  be  due 
to  conducting  wires  getting  too  near  the  tube  and  causing 
a  cross  spark. 

Reverse  Currents. — Reverse  current  has  been  mentioned 
above;  it  is  in  many  respects  the  bete  noire  of  the  radiologist. 
These  currents  cause  a  deterioration  of  the  tube,  as  the 
platinum  of  the  antikathode  becomes  disintegrated  gradu- 
ally and  is  deposited  in  the  form  of  grey  dust  on  the  wall 
of  the  tube,  which  becomes  hard  and  useless.  They  further 
lead  to  the  production  of  secondary  rays,  which  tend  in 
radiography  to  make  the  photos  foggy  and  ill  defined. 

Reverse  currents  are,  in  point  of  fact,  induced  currents 
such  as  are  generated  in  an  ordinary  du  Bois  Raymond 
coil.  The  current  induced  on  breaking  the  primary  has 
the  same  direction  as  the  inducing  current,  and  that  induced 
on  closing  has  the  opposite  direction.  It  is  called  the 
reverse  or  closing  current. 

Apart  from  the  inconvenience  in  photography,  reverse 
current  makes  the  reading  of  a  milliamperemeter  difficult 


362       MANUAL  OF  PHYSIO -THERAPEUTICS 

and  inaccurate.  Every  effort  is  made,  therefore,  to  suppress 
or  minimize  it.  To  this  end  valve  tubes  and  mechanical 
rectifiers  are  used  with  more  or  less  success,  being  placed 
on  the  secondary  circuit.  The  principle  underlying  all 
these  devices  is  to  interpose  a  maximum  resistance  to  the 
reverse  current,  only  allowing  the  normal  or  unidirectional 
current  to  pass.  For  this  purpose  we  use  a  valve  tube  such 
as  Pilon's,  or  more  seldom  now  the  spark  gap.  The  working 
of  the  latter  is  based  on  the  fact  that  the  voltage  of  the 
reverse  current  is  considerably  less  than  the  normal  or 
direct  current.  It  is  therefore  arranged  to  interpose  enough 
resistance  in  the  circuit  to  choke  off  the  reverse  current 
while  allowing  the  stronger  current  to  pass.  For  this  we 
use  a  mica  plate  and  point  spark  gap,  the  positive  pole 
being  connected  with  the  point.  The  current  passes  much 
more  easily  from  the  point  to  the  plate,  but  even  if  there 
be  a  small  gap  the  reverse  current  may  pass. 

In  the  mechanical  rectifier  we  arrange  to  insure  that  at 
the  moment  of  making  the  primary  current  the  secondary 
current  is  kept  open  by  interposing  a  large  spark  gap, 
which,  however,  ceases  the  moment  the  primary  current  is 
broken. 


CHAPTER  IV 
HIGH-FREQUENCY  AND  SINUSOIDAL  TREATMENT 

WE  can  best  understand  the  nature  of  the  currents  employed 
if  we  consider  the  action  of  the  Ley  den  jar.  It  is  well 
known  that  when  a  discharge  takes  place  the  spark  does 
not  represent  a  single  exchange  of  the  exact  amount  required 
to  equalize  the  electric  conditions  of  the  two  armatures. 
Equilibrium  is  only  reached  at  the  rate  of  about  J-  million 
discharges  per  second,  and  the  relative  condition  of  the 
two  armatures  undergoes  this  number  of  alterations  per 
second;  if  the  human  body  be  connected  with  the  armatures, 
the  application  differs  entirely  from  faradism  and  galvanism. 
While  the  amperage  is  very  low,  the  voltage  is  very  high. 
With  the  best  types  of  high-frequency  machines  the  current 
runs  up  to  1,500  or  more  milliamperes,  and  with  some 
types  suitable  for  diathermy  up  to  4,000  milliamperes. 
Of  course,  nothing  like  this  can  be  obtained  even  from  the 
most  powerful  static  machines. 

Source  of  the  Current. — Any  source  of  high-tension 
current  can  be  used,  but  a  coil  or  alternating  current  trans- 
former is  preferable  to  a  static  machine;  for  useful  work 
a  12-inch  coil  is  needed.  Using  the  direct  current  with  a  coil 
of  this  size,  we  have  found  Gaiffe's  or  Bondel's  gas-mercury 
break  most  satisfactory.  The  special  advantages  claimed 
for  it  with  some  reason  are : 

1.  Great  amperage — the  amperage  ranging  from  20  to 
50  amperes  at  a  pressure  of  220  volts,  a  name  passing 
between  the  secondary  terminals  similar  to  that  with  a 
Wehnelt  break. 

At  that  voltage  the  average  break  passes  very  little  above 
10  amperes,  with  the  result  that  the  spark  is  thin  and  greater 
exposure  required  in  radiography.  The  principle  on  which 
this  heavy  amperage  is  passed  is  that  of  multiple  contacts, 

363 


364        MANUAL  OF  PHYSIO-THERAPEUTICS 

the  number  of  interruptions  per  minute  reaching  6,000  and 
over.     This   interrupter   is  generally  arranged  to   operate 


FIG.  188. — OUDIN'S  RESONATOR  AND  OIL  CONDENSER. 

with  ordinary  coal-gas  as  the  dielectric,  and  the  best 
results  are  so  obtained  rather  than  with  spirit  used  in 
some  types. 


HIGH-FREQUENCY  TREATMENT  365 

2.  The  interrupter  is  capable  of  very  considerable  adjust- 
ment, either  for  feeble  currents  suitable  for  therapeutic 
work,  or  powerful  currents  required  for  instantaneous 
radiography.  The  driving  speed  is  adjustable  from  a  low 
minimum  to  a  high  maximum  number  of  interruptions  per 
second.  There  is  freedom  from  danger  of  short  circuit, 
because  when  the  break  stops  contact  is  broken.  The  break 
can  be  run  independently  of  any  current  through  the 
primary  winding — i.e.,  once  the  break  is  started  the  primary 
current  can  be  switched  off  or  on  without  the  interrupter 
being  stopped  or  restarted.  It  is  very  quiet  running,  con- 
trasting very  favourably  in  this  way  with  the  very  noisy 
Wehnelt. 

With  all  this  admitted,  we  have  to  say  that  the  perfect 
interrupter  has  yet  to  be  discovered,  and  we  have  had  a 
good  many  mornings'  work  spoiled  by  a  breakdown  in  the 
autonome.  This,  it  must  be  admitted,  was  due  usually  to 
want  of  cleaning  when  the  interrupter  had  been  in  very 
steady  employment.  Cleaning  is  an  ordeal  postponed  as 
long  as  possible,  but  usually  has  to  be  done  every  four  or 
five  weeks  to  keep  the  machine  in  good  order.  A  good 
deal  depends  on  the  gas  used  as  dielectric,  for  if  it  is  rich 
in  carbon  the  choking-up  occurs  sooner.  The  carbon 
frequently  chokes  up  certain  holes  in  the  mechanism,  and 
a  piece  of  wire  or  a  pin  are  needed  to  clean  it  out.  The 
mercury  requires  turning  out  and  filtering  through  a  piece 
of  chamois  leather.  This  is  a  dirty,  "  messy  "  sort  of 
business,  and  is  preferably  done  by  a  mechanic  assistant. 

The  autonome  is  a  very  neat  and  easily  carried  about 
piece  of  apparatus,  and  the  appearance  of  the  complete 
machine  may  be  seen  in  Fig.  189.  As  regards  the  connec- 
tions, the  upper  portion  is  screwed  into  the  vessel  V  by 
the  screws  e,  e.  The  terminals  I1,  I2,  and  I3  are  connected 
with  the  corresponding  terminals  of  the  switchboard.  M  is 
a  vulcanite  cap  covering  the  motor  driving  apparatus.  To 
use  the  interrupter  we  connect  the  gas-supply  tube  with 
the  tap  R,  care  being  taken  that  the  gas-supply  is  higher 
than  the  motor  tap,  so  that  the  tube  does  not  sag  or  kink 
or  the  mercury  be  thrown  back  into  the  rubber  tube  and 
so  check  the  pressure  of  the  gas.  Open  the  inlet  tap  E 


360        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  the  outlet  tap  R1,  and  turn  on  the  gas,  and  then  put 
a  lighted  match  to  R1. 

At  first  air  is  driven  out  only,  then  gas  and  air,  and 
then  pure  coal-gas  burning  with  a  yellow  flame.  The  tap  Rl 
may  now  be  closed,  and  the  interrupter  is  ready  for  use. 
The  vulcanite  spindle  B  is  given  a  whirl  with  the  hand,  and 
if  the  current  be  on  in  the  motor  circuit  the  interrupter  will 
run  smoothly.  The  current  passes  through  the  body  of 


FIG.  189. 


THE  AUTONOME   OK  GAS-MERCURY  INTERRUPTER. 

(UAIFFE.) 


the  cone  C,  the  mercury  being  thrown  out  in  small  jets 
through  the  four  holes  marked  6  against  the  tooth  d,  and 
through  the  motor  winding. 

No  current  passes  through  the  primary  circuit  of  the 
coil  until  the  turnover  switch  on  the  board  is  turned  to 
normal.  The  current  then  passes  through  a  second  tooth 
on  the  side  of  the  break  opposite  to  d,  and  through  the 
primary  circuit.  When  the  switch  is  put  to  the  intensive 
side  the  current  passes  via  another  peculiarly  constructed 


HIGH-FREQUENCY  TREATMENT  367 

contact,  which  immediately  doubles  the  rate  of  interruption 
with  the  same  mechanical  speed  of  the  motor,  part  of  the 
interrupter  thus  giving  a  very  large  output  in  the  secondary 
circuit. 

This  apparatus,  when  used  in  conjunction  with  the  high- 
frequency  d'Arsonval  couch,  can  easily  pass  1-5  amperes 
when  holding  the  two-handle  electrodes  by  the  hands;  if, 
however,  other  electrodes  be  connected  in  parallel,  currents 
as  high  as  4  amperes  can  be  obtained  and  a  general  glow 
established  all  over  the  body. 

Effleuve  Effects. — These  are  obtained  by  means  of  the 
Oudin  resonator,  which  can  be  supplied  mounted  with 
the  apparatus  as  in  Fig.  188,  or  standing  separately.  It 
consists  of  a  helix  of  bare  copper  wire  wound  round  an 
insulating  cylinder  with  a  sliding  contact,  to  permit  of 
obtaining  the  condition  of  electrical  resonance  in  order 
to  produce  long  and  soft  effleuves  without  tendency 
to  spark  discharge.  The  coils  of  wire  between  the  lower 
end  of  the  helix  and  the  movable  point  form  part  of  the 
oscillating  circuit,  which  includes  the  condenser  and  spark 
gap;  the  upper  end  is  the  one  to  which  the  effleuve  brush 
is  connected  when  the  unipolar  treatment  is  given.  In  the 
bipolar  treatment  the  effleuve  brush  is  connected  to  the 
lower  end,  and  the  patient  may  hold  an  electrode  which  is 
attached  to  the  upper  end;  the  former,  however,  is  the 
most  favoured  and  generally  the  most  pleasant  form  of 
treatment.  The  resonator  modified  by  d'Arsonval  has  also 
found  favour  with  some  workers.  We  have  an  air-cored 
transformer  with  primary  of  a  few  turns  which  forms 
part  of  the  oscillating  circuit,  including  condenser  and 
spark  gap,  but  no  direct  metallic  connection  between  it 
and  the  secondary,  which  is  composed  of  a  large  number 
of  turns  wound  on  an  insulating  cylinder,  generally  vulcanite. 
In  the  bipolar  treatment  the  primary  is  placed  in  the  middle 
of  the  secondary,  and  the  patient  connected  to  one  end  by 
holding  a  metallic  handle,  whilst  the  effleuve  brush  is  con- 
nected to  the  other.  Here,  again,  the  unipolar  method  is 
most  pleasant,  presenting  no  tendency  for  faradic  sensa- 
tions, and  is  attained  by  sliding  the  primary  to  the  end  of 
the  secondary  and  coupling  the  two  circuits  together  by 


368        MANUAL  OF  PHYSIO-THERAPEUTICS 

means  of  a  wire.  The  intensity  of  the  effleuve  discharge 
may  then  be  regulated  by  moving  the  primary  from  one 
end  to  the  other  of  the  secondary.  For  intense  discharges 
in  the  vacuum  electrodes  both  the  Oudin  and  d'Arsonval 
type  give  excellent  results  when  used  in  conjunction  with 
the  oil  condenser  and  multiple  spark  gap. 

High-Frequency. 

The  Coil  used  is  of  the  usual  type,  as  employed  for  X  rays 
(which  see,  p.  352). 

If  the  current  available  be  of  the  alternating  type,  then 
the  interrupter  described  there  will  require  to  be  replaced 
by  one  equally  simple  in  operation  and  of  similar  appearance, 
but  differently  arranged  internally. 

We  require  a  table,  as  figured  below,  with  a  large  6-inch 
dial  hot-wire  milliamperemeter  dead-beat  with  zero  adjust- 
ment. 

A  silent  spark  gap,  or  spintermeter  (Fig.  191),  is  now  used, 
comprising  nine  gaps  entirely  closed  and  requiring  no 
cleaning.  The  spark  takes  place  between  silver  contacts 
across  a  gap  of  a  few  milliamperemeters,  with  no  noise 
beyond  a  slight  hissing  sound.  This  is  a  distinct  advance 
on  the  globe  spintermeter,  which  was  noisy  and  sometimes 
disturbed  nervous  patients. 

On  the  lower  shelf  of  the  table  is  a  condenser  consisting 
of  a  special  vulcanite  tank  with  special  glass  plates  separated 
by  tin-foil  and  immersed  in  petroleum  oil,  which  acts  as 
the  dielectric. 

All  efneuve  effects  are  enhanced  by  the  use  of  the  Oudin 
Resonator.  This  consists  of  about  200  feet  of  copper  wire 
wound  helical  fashion  around  a  vulcanite  or  wooden  stand. 
It  ends  at  the  top  in  a  metallic  knob,  to  which  is  attached 
the  wire  or  lead  to  the  electrode  used  for  efneuve  or  other 
local  treatment.  The  condenser — or  Leyden  jars,  if  used — 
is  connected  with  the  bottom  of  the  helix,  and  also  with  a 
point  on  the  surface  of  the  wire  helix  which  varies  according 
to  the  use  to  which  the  resonator  is  put.  The  adjustment 
of  the  clip  is  known  as  tuning  up  the  resonator.  That 
portion  of  the  helix  lying  between  the  attachment  from  the 


HIGH-FREQUENCY  TREATMENT 


369 


condenser  acts  as  a  primary  coil.  The  upper  portion, 
acting  as  the  resonator,  may  be  compared  to  the  secondary 
coil,  and  immensely  increases  the  power  of  the  apparatus. 

A  wire  is  usually  attached  to  the  bottom  of  the  solenoid, 
and  then  connected  to  a  gas  or  water  pipe  to  insure  an 
earth  connection. 


FIG.  190. — STAND  WITH  OIL  CONDENSER  AND  MILLIAMPEREMETER. 


The  best  effleuve  can  be  got  from  the  type  of  Oudin 
wound  on  an  oak  frame,  about  3  feet  6  inches  high  and  on 
a  separate  stand. 

An  alternative  to  the  employment  of  this  is  the  Tesla 
transformer,  consisting  of  a  primary  helix  of  four  turns  of 
thick  wire  carrying  the  current  from  the  condenser,  which 
surrounds  a  much  larger  number  of  turns  of  finer  wire, 

24 


370        MANUAL  OF  PHYSIO-THERAPEUTICS 

which  passes  round  a  vulcanite  cylinder.  A  space  of  about 
2  inches  lies  between  the  larger  primary  coil  and  the  secondary 
helix.  The  secondary  coil  can  be  moved  in  and  out  of  the 
primary  in  the  Tesla  arrangement,  varying  the  strength  of 
the  induced  current.  In  Gaiffe's  modification  known  as 
the  d'Arsonval  transformer  the  primary  coil  moves  back- 
wards and  forwards,  and  attachment  is  made  for  the  effleuve 
wire  at  the  right-hand  end  of  the  secondary  coil,  where 
there  is  a  special  terminal  for  it. 


FIG.  191. — MULTIPLE  SILENT  SPARK  GAP. 
Does  not  require  cleaning  or  adjustment. 

These  differences  are  little  more  than  details  in  individual 
makes;  construction  and  the  result  is  much  the  same  in 
either  case. 

Methods  of  Application.  —  1.  Auto-condensation  on  the 
couch  is  probably  the  most  commonly  employed  method 
in  general  electro-therapeutics.  Here  500  to  1,500  milli- 
amperes  and  over  are  passed  into  the  patient,  who  lies  on 
the  couch,  really  acting  as  one  of  the  armatures  for  a  Ley  den 
jar.  The  other  armature  is  represented  by  a  large  piece 
of  zinc  sheeting  attached  to  the  lower  surface  of  the  couch. 
The  patient  holds  on  to  handles  which  are  attached  to  the 
arms  of  the  couch,  and  connected  directly  with  the  copper 
solenoid  of  the  high-frequency  apparatus.  This  treatment 
is  very  soothing  to  excitable  people,  neurotics,  etc.,  and 
favourably  influences  cases  of  neurasthenia  with  associated 
hyperpyesis.  Local  treatment  of  this  kind  may  be  given 


HIGH-FREQUENCY  TREATMENT 


371 


by  connecting  up  a  plate  of  zinc,  which  is  placed  uncovered 
on  the  patient's  epigastrium  or  part  to  be  treated.  In  this 
case  the  handles  are  not  held  by  the  patient. 

2.  Auto-conduction  is  not  used  so  commonly.  In  it  the 
patient  stands  inside  an  enormous  solenoid  forming  the 
secondary  of  a  gigantic  induction  coil.  This  method  has 
rather  fallen  into  desuetude.  The  risk  of  cross-sparking  is 
very  considerable,  and  alarms  nervous  patients. 


FIG.   192. — THE  D'ARSONVAL  GAIFFE  INSTALLATION  FOR  HIGH- 
FREQUENCY,  STATIC  ELECTRICITY,  AND  X  EATS. 


3.  Vacuum  Electrodes. — Here  the  current  is  passed  to  the 
patient  by  means  of  a  special  form  of  vacuum  tube  fixed 
on  a  vulcanite  handle,  such  as  that  of  Dr.  Bisserie.  The 
tube  is  similar  to  a  Giessler  tube,  and  a  practical  point  to 
remember  with  it  is  to  always  put  it  into  contact  with  the 
patient  before  turning  the  current  on  or  off.  Given  on  the 
bare  skin,  the  sensation  imparted  is  not  unpleasant,  but 


372        MANUAL  OF  PHYSIO-THERAPEUTICS 

through  clothes  it  is  slightly  painful.  The  area  of  skin 
treated  becomes  flushed,  a  local  passive  congestion  being 
induced. 


FIG.  193. — HEDGEHOG  PATTERN  EFFLEUVE  BRUSH  FOR 

APPLYING  HIGH-FREQUENCY  CURRENT  DISCHARGES. 

It  is  made  up  of  closely  packed  metal  bristles,  and  very  evenly  cut 

into  a  dome  shape,  producing  soft  and  pleasant  effleuves. 

The  effleuve  discharge  is  another  form  of  treatment,  and 
more  suitable  for  some  cases.  It  is  entirely  different  from 
the  vacuum  tube  in  its  modus  operandi,  there  being  no 


FIG.  194. — PROFESSOR  DOUMER'S  EECTAL  ELECTRODE  FOR 
TREATMENT  OF  HEMORRHOIDS,  ETC. 

local  heating — the  sensation  being  likened  to  the  fall  of 
snow.  Figures  of  the  various  types  of  effleuve  brushes  are 
given  below.  It  is  usually  administered  from  a  resonator 
of  the  Oudin  or  d'Arsonval  type. 


FIG.  195.  -GRAND  MODEL  GRIP  HANDLE  FOR  PATIENT,  so  ARRANGED 

THAT  IT  CAN  BE  USED  AS  A  SINGLE  POLE  OR  DOUBLE  ELECTRODE. 

This  electrode  can  be  used  for  liigh-f requency  or  diathermy 
treatment. 

Measuring  the  Current. — The  strength  of  the  current  will 
depend  on  the  width  of  the  spark  gap,  but  can  also  be 
graduated  by  regulating  the  current  from  the  induction 


HIGH-FREQUENCY  TREATMENT 


373 


coil  which  supplies  the  Ley  den  jars.  Fig.  196  represents 
a  hot-wire  milliamperemeter.  The  strength  used  in  high- 
frequency  treatment  will  vary  considerably  with  different 
operators  and  with  the  patient,  but  runs  up  as  high  as 


FIG.  196. — HOT-WIRE  MILLIAMPEREMETER. 


1,500  milliamperes.  In  auto-conduction  the  full  power  of 
the  machine  is  commonly  employed,  but  measurement 
cannot  be  made;  in  auto-condensation  the  galvanometer  is 
placed  between  the  patient  and  his  point  of  attachment, 
and  in  local  applications  it  should  be  in  series  with  the 


FIG.  197. — ADJUSTABLE  HANDLE  OF  DR.  BISSERIE. 

By  means  of  a  sliding  contact  the  amount  of  current  passing  to  the 
patient  is  regulated.  When  the  sliding  contact  is  brought  near 
to  a  small  ball,  a  portion  of  the  current  is  diverted  into  the  handle 
held  by  the  operator.  This  reduces  the  current  of  the  electrode 
applied  to  the  patient.  This  is  specially  useful  for  internal 
treatment. 

patient.     In  brush  discharges  the  appearance  of  the  effleuve 
is  a  guide  to  the  current  strength. 

Therapeutic  Value  of  High-Frequency.—  Rather  extrava- 
gant claims  were  made  for  this  method  of  treatment  on  its 
introduction  about  seventeen  years  ago ;  medical  men  became 
over-enthusiastic  and  went  to  extremes.  The  word  "  caught 


374        MANUAL  OF  PHYSIO-THERAPEUTICS 

on  "  with  patients,  and  the  treatment  was  boomed  to  an 
absurd  extent.  From  this  there  was  a  marked  and,  one 
might  say,  overreaction.  We  can  only  speak  from  our 
own  experience.  Some  of  us  have  been  in  the  habit  of 
employing  high-frequency  for  various  conditions  daily  for 
the  past  ten  years  or  more;  during  the  past  two  years 
hundreds  of  officers  with  neurasthenia,  neuritis,  insomnia, 
and  other  conditions,  have  been  treated  by  us  with  high- 
frequency,  and  the  general  results  have  been  remarkably 
good.  Some  years  ago  a  well-known  worker  in  electricity 
told  the  writer  he  regarded  a  feather-bed  as  of  much  use 
therapeutically  as  a  high-frequency  couch.  Such  expres- 
sions of  opinion  are  extreme  and  absurd,  and  merely  reveal 
the  fact  that  the  speaker  has  not  been  working  among  the 
class  of  patient  or  variety  of  disease  likely  to  be  benefited, 
or,  if  so,  has  simply  allowed  himself  to  be  blinded  by  pre- 
judice. We  may  take  neurasthenia  as  a  typical  condition 
which  does  unquestionably  improve  in  the  majority  of 
cases  under  auto-condensation. 

Let  not  the  sceptic  reply,  "  Such  patients  improve  with 
bread  pills."  Dealing  with  the  excited  and  worrying 
neurasthenic  one  cannot  but  be  impressed  with  the  way 
the  strained  look  quickly  disappears,  the  excitement  goes, 
and  at  night  sleep  comes.  Many  of  these  people  have  an 
associated  hyperpyesis  or  commencing  arterio-sclerosis. 
Twenty  minutes  on  the  couch  will  bring  the  pressure  down 
20  mm.  Hg,  in  some  cases  relieving  the  headache  and 
malaise.  Metabolism,  where  faulty,  is  improved,  and  there 
is  an  increase  in  the  output  of  uric  acid  and  urea  in  the 
urine. 

The  improved  tissue  oxidation  can  be  made  use  of  in 
the  later  stages  of  Weir  Mitchell  treatment,  when  patients 
are  inclined  to  get  "  stuffed  up,"  lethargic,  and  bilious. 
The  elimination  of  waste  products  by  the  kidneys  is  en- 
couraged, and  the  development  of  "a  bilious  attack  " 
averted. 

In  various  digestive  disorders  general  d'Arsonvalization 
of  the  patient  does  good.  We  have  used  the  gastric  mono- 
polar  electrode  with  benefit  in  neuralgia  of  the  stomach 
and  gastric  hypersesthesia.  A  white  metal  or  aluminium 


HIGH-FREQUENCY  TREATMENT  375 

electrode,  4  inches  by  4  inches,  is  used.  The  skin  over  the 
part  treated  gets  red,  and  may  even  develop  papules,  but 
the  counter-irritant  effect  does  good.  Sinclair  Tousey 
recommends  high-frequency  in  constipation,  but  of  that 
we  have  had  no  favourable  experience,  and  prefer  sinusoidal 
treatment.  In  the  pain  and  tenderness  over  the  colon  in 
that  intractable  condition  mucous  colitis  the  vacuum  tube, 
used  thoroughly,  is  of  very  great  value.  It  is  at  once 
counter-irritant  and  acts  by  suggestion,  the  neurotic  type 
of  patient  being  impressed  by  the  mystery  of  the  coloured 
illumination  of  the  tube. 

In  cases  of  insomnia  the  treatment  should  be  given  late  in 
the  day,  and  appears  to  have  a  very  considerable  influence 
in  inducing  a  restful  feeling  at  bedtime.  Doubtless  the  fall 
in  blood-pressure  helps  in  most  cases.  The  time  should 
not  be  too  long — about  fifteen  minutes — as  overtreatment 
aggravates  the  condition.  A  few  minutes'  mild  application 
of  the  vacuum  tube  has  a  soothing  effect  also. 

It  would  at  once  suggest  itself  that  in  chronic  or  subchronic 
disturbances  of  the  metabolism,  such  as  obesity,  gout,  and 
rheumatism,  high-frequency  is  of  value,  and  this  we  find 
in  practice  to  be  true.  Of  course,  for  the  material  re- 
duction of  obesity  the  Bergonie  apparatus  holds  the 
field. 

The  effleuve  or  vacuum  tube  applied  locally  is  very 
beneficial  for  that  trying  minor  ailment  chilblains,  or 
erythema  pernio.  In  cases  of  piles,  pruritus  ani,  and 
painful  fissure  also,  the  special  rectal  electrode  can  be  used 
with  great  benefit.  Acne  vulgaris  is  another  affection 
which  often  yields  quickly  to  the  local  vacuum  tube.  We 
have  seen  a  case  of  severe  acne  rosacea  greatly  benefited,  but, 
as  is  well  known,  this  condition  is  not  easy  to  cure. 

We  have  experience  of  several  interesting  cases  of  alopecia 
areata  and  premature  whiteness  of  the  hair  caused  by  the 
stress  of  the  war,  crashes  in  an  aeroplane,  and  so  forth, 
treated  with  the  vacuum  tube,  with  the  result  that  the 
hair  began  to  grow  steadily.  One  case  in  particular  was  so 
sparsely  covered  that  he  entered  hospital  with  his  head 
bandaged.  The  cure  was  slow,  but  in  a  year's  time  he  had  a 
thick  growth  of  good  hair.  In  another  case  the  colour 


376  MANUAL  OF  PHYSIO-THERAPEUTICS 

came  back  to  a  patient's  hair,  which  was  snow  white  on 
commencing  treatment. 

In  neuritis  we  use  both  auto-condensation  to  combat  the 
toxaemia  and  deficient  metabolism,  and  the  local  glass 
electrode  as  a  counter-irritant.  The  tenderness  in  some 
cases  is  so  extreme  that  local  treatment  cannot  at  first  be 
borne. 

The  benefit  in  cases  of  high  blood-pressure  before  any 
considerable  arterio-sclerosis  has  established  itself  is  well 
known.  Moutier  recorded  as  large  reductions  as  40  to 
50  mm.  Hg.  Reaction  always  occurs,  but  as  a  rule  further 
treatment  causes  a  second  reduction,  and  the  general  effect 
is  to  induce  a  lower  level.  We  have  used  it  with  quite  a 
number  of  medical  men,  and  demonstrated  the  fall  by  means 
of  the  sphygmomanometer  to  some  who  were  inclined  to 
be  sceptical. 

It  will  be  thus  seen  that  the  field  for  the  use  of  high- 
frequency  is  a  very  wide  one — one  may  say  wider  even  than 
that  of  either  galvanism  or  faradism,  except  as  regards 
diagnostic  purposes. 

One  caution  is  necessary.  Every  few  months  we  come 
across  a  patient  who  complains  of  headache  coming  on 
immediately  after  the  treatment — a  cephalalgia  of  quite  a 
severe  type.  The  cause  or  reason  for  the  treatment  bringing 
this  on  is  difficult  to  explain  or  be  clear  about,  but  we  have 
no  doubt  about  the  genuineness  of  the  complaint.  We 
usually  stop  the  treatment  at  once. 

~  ^        X  ^^ 

Diathermy. 

Diathermy  is  a  form  of  thermo-therapy  which  utilizes 
electrical  energy  for  the  production  of  thermal  effects  in 
the  body  tissues,  but  is  quite  a  new  departure  from  the 
procedures  formerly  employed  in  clinical  work. 

These  were  what  are  known  as  exogenous  methods — 
poultices,  warm  baths,  radiant  heat,  and  the  like.  In 
diathermy  the  source  of  contributory  heat  is  endogenous, 
the  heat  being  produced  actually  in  the  deeper-lying  tissues. 
As  regards  the  skin,  Somerville  a  good  many  years  ago 
pointed  out  that  high-frequency  raised  the  surface  tem-= 


HIGH-FREQUENCY  TREATMENT  377 

perature  considerably — from  |°  to  17°  F.  Diathermy  is  but 
a  variant  of  high-frequency,  and  with  it  we  can  go  further 
and  raise  the  temperature  of  the  deeper  tissues  to  an  extra- 
ordinary extent.  The  degree  depends  on  the  ohmic  resis- 
tance and  on  the  square  of  the  intensity  of  the  current. 
The  underlying  physical  principle  is  what  is  known  as  the 
Joule  effect,  on  which  depends  the  lighting  of  lamps  and 
the  heating  of  rheostats.  Electricity,  when  passed  through 
a  resisting  medium  such  as  a  slender  nickel  wire,  becomes 
converted  into  heat;  but  if  we  substitute  the  body  tissues, 


FIG.  198. 

Upper  tracing  shows  oscillations  from  ordinary  high-frequency 
apparatus.  Lower  tracing  shows  oscillations  from  diathermy 
apparatus.  (From  the  author's  work  on  "  Medical  Electricity," 
published  by  Mr.  H.  K.  Lewis.) 

which  form  an  electrolyte  for  the  wire,  the  result  is  the 
same — heat  is  generated.  If,  however,  the  current  is 
continuous,  as  in  galvanism  and  ionic  treatment,  we  know 
the  effect  to  be  largely  chemical,  and  the  amount  of  heat 
generated  is  relatively  small.  On  the  other  hand,  with  an 
alternating  current  the  thermal  effect  is  practically  the  sole 
manifestation  of  the  passage  of  the  current.  To  produce 
a  considerable  amount  of  heat  with  a  galvanic  current  we 
should  require  to  use  a  powerful  current,  and  the  almost 
immediate  effect  would  be  a  painful  electrolytic  burn.  With 


378       MANUAL  OF  PHYSIO-THERAPEUTICS 

a  purely  alternating  current  violent  tetanic  spasm  of  the 
muscles  would  ensue. 

We  are  thus  driven  back  on  something  of  the  nature  of 
high-frequency  currents.  With  a  sinusoidal  current,  where 
the  alternations  are  39  to  the  second,  muscular  tetanus  is 


FIG.  199. 

The  above  figure  shows  some  of  the  many  ways  in  which  electrodes 
can  be  conveniently  connected  and  supported  on  the  body. 

produced;  and  even  if  the  alternations  are  so  frequent  as 
5,000  per  second,  we  may  merely  attain  the  same  result. 
Beyond  this  frequency  "the  muscle  becomes  less  and  less 
responsive,  and  does  not  react  at  all  to  the  millions  of 
stimuli  per  second  which  are  produced  by  high-frequency 


HIGH-FREQUENCY  TREATMENT  379 

oscillations.     D'Arsonval    showed,    however,    that    intense 
high-frequency   currents  passed  through  the   tissues  may 


FIG.  200. 

1  to  9,  "Limpet"  aseptic  rubber  belts.  10,  "Limpet"  terminal 
attachment  for  slipping  beneath  belt  after  electrode  has  been 
fixed  in  position.  11,  Cutting  electrodes  of  any  desired  shape  from 
non-oxidizable  plastic  electrode  metal.  12,  Old  type  electrode 
with  fixed  terminal;  the  dotted  line  shows  the  position  where 
a  fracture  invariably  occurs  after  a  short  time  in  use.  The 
electrode  is  fitted  in  a  non-aseptic  absorbent  case.  Entirely 
superseded  by  "Limpet"  system.  13,  Showing  section  of 
"Limpet"  aseptic  rubber  belts;  the  wedge-shaped  edges  render 
the  belt  more  comfortable  to  the  patient. 

raise  their  temperature  very  considerably.  This  observer, 
indeed,  produced  such  heat  in  experimenting  on  animals 
as  to  cook  the  tissues  in  certain  portions  of  the  body  in  a 


380        MANUAL  OF  PHYSIO-THERAPEUTICS 

few  minutes.  By  the  use  of  the  apparatus  described  under 
High-Frequency  we  can  produce  either  these  or  diathermy 
currents  by  a  simple  adjustment.  We  reduce  the  voltage 
to  about  20,000,  and  raise  the  amperage  by  the  same  adjust- 
ment to  from  |  to  3  amperes. 

The  current  is  much  the  same  as  high-frequency,  but 
the  oscillations  very  much  condensed,  the  time  between 
them  being  very  much  shorter.  We  use  what  is  known  as 
damped  oscillations,  avoiding  long  intervals  between  the 
oscillations,  such  as  we  use  in  high-frequency  currents. 

If  the  apparatus  be  properly  regulated,  the  length  of 
each  group  of  oscillations  is  equal  to  the  length  of  the  pause, 
and  under  these  conditions  the  best  results  are  obtained. 

Alternatively  to  the  spark  gap  and  12-inch  coil  we  may 
use  the  special  diathermy  apparatus,  the  spark  gap  of 
which  is  really  very  similar  to  the  Telefunken  spark  gap 
used  in  wireless  telegraphy. 

There  is  a  frame  containing  two  pairs  of  electrodes,  each 
with  a  silver  disk  in  the  centre,  kept  apart  by  two  mica 
rings.  It  is  between  these  silver  disks  that  the  discharge 
takes  place.  A  small  resistance  coil  is  connected  in  parallel 
with  one  of  the  pairs  of  copper  electrodes,  so  reducing  the 
discharge  voltage  and  increasing  the  rate  of  sparking. 

To  prevent  the  electrodes  from  getting  overheated,  large 
copper  disks  are  fitted  to  the  centre  and  end  of  each  pair 
which  act  as  radiators. 

Two  strong  glass  plates  are  used  to  insulate  these  from 
electrodes  from  the  case,  which  is  placed  over  the  whole 
of  the  spark  gap,  since  it  is  not  safe  to  risk  touching  it  on 
account  of  the  high-tension  low  periodicity  A.C.  current 
at  the  terminals. 

The  current,  which  is  an  alternating  one,  is  turned  off  and 
on  by  switch  S,  arid  passing  through  R,  the  resistance 
(subject  to  regulation),  it  flows  to  step-up  transformer  T, 
where  the  voltage  is  multiplied  by  10  with  an  output  of 
2  kilowatts.  The  condenser  K  becomes  charged,  and  dis- 
charges itself  automatically  through  the  spark  gap  F.  This 
is  of  the  silent  type,  the  sound  being  almost  nil.  The 
number  of  oscillations  is  about  a  million  a  second.  The 
high-frequency  currents  thus  generated  in  the  oscillating 


HIGH-FREQUENCY  TREATMENT  381 

current  are  carried  to  a  movable  coupling  coil  M1,  made 
up  of  several  windings.  This  coil  is  manipulated  by  a 
lever  H,  which  brings  it  into  relation  with  another  coil,  M z 
—a  fixed  one,  in  which  a  current  is  generated  varying  in 
intensity  with  the  distance  between  the  two  coils;  in  a 


FIG.  201. — THE  DIATHEKMY  APPARATUS. 

word,  in  inverse  ratio  to  the  distance  between  them  as 
estimated  by  a  hot-wire  meter.  This  is  called  the  magnetic 
coupling. 

Coil  J/2  is  subdivided  into  0,  1,  and  2  sections,  terminals 
from  which  are  connected  with  the  patient.  If  there  is 
much  resistance,  as  in  the  whole  body,  0  and  2,  the  elec- 
trodes being  held  by  the  patient's  hands,  and  if  there  is 
little  resistance,  as  where  it  is  a  question  of  treating  a 
single  joint,  then  0  and  1  are  used.  The  maximum  current 
strength  is  2^  amperes,  but  this  is  seldom  requisite  or 


382        MANUAL  OF  PHYSIO-THERAPEUTICS 

desirable.  Any  faradic  effect  is  avoided  by  means  of  the 
special  spark  gap  carefully  adjusted.  It  must  be  prevented 
at  all  times. 

A  very  easy  and  practical  method  of  testing  diathermy 
currents,  if  in  a  plate  or  saucer  of  egg  or  meat  albumen, 
when  very  soon  will  be  seen  from  the  process  of  coagulation 
in  what  direction  the  current  is  flowing,  and  in  some  degree 
with  what  intensity. 

Fulgurating  currents  of  high  amperage  are  only  used  in 
surgery,  and  with  them  we  have  nothing  to  do.  Medical 
currents  of  lower  amperage  are  used  where  no  destruction 
of  tissue  is  needed  or  desired.  The  heat  produced  is 


FIG.  202. — DIATHERMY  ELECTRODES. 

developed  in  the  depths  of  the  tissues,  as  above  stated, 
while  the  patient  only  feels  it  on  the  skin  surface. 

The  sensation  of  heat  persists  a  considerable  time  after 
the  treatment  ceases.  As  regards  temperatures  borne  at 
about  112°  F.  (45°  C.)  the  sensation  becomes  painful,  and 
cannot  be  tolerated  any  higher.  An  active  hypersemia  is 
induced,  which  in  certain  conditions  cannot  but  be  beneficial. 

The  therapeutic  effects  are  at  once  decongestive  and 
analgesic.  Pain  is  materially  relieved  in  such  conditions 
as  sciatica  and  neuritis  elsewhere,  the  various  arthrites, 
and  even  in  neuralgia. 

Method  of  Application. — The  type  and  manner  of  using 
the  electrodes  calls  for  special  care  and  consideration. 


HIGH-FREQUENCY  TREATMENT  383 

There  is  no  difficulty  in  inflicting  severe  burns  if  care  be 
not  exercised  at  all  times.  Lewis  Jones  recommended  bare 
metal  electrodes  of  pure  tin  well  adapted  to  the  part,  and 
applied  well  moistened  with  strong  saline  solution.  The 
trouble  with  these  is  uniform  adaptation  to  surfaces  which 
are  frequently  irregular. 

Sharp  sparking  occurs  from  points  not  actually  in  contact 
with  the  skin,  with  the  most  unpleasant  effects  on  the 
patient.  The  difficulty,  moreover,  is  that  the  personal 
factor  both  as  regards  attendant  and  patient  vary  greatly. 
If  the  medical  man  is  not  carrying  out  the  treatment  him- 
self, the  attendant  may  be  careless  and  the  patient  long- 
suffering,  thinking  the  sparking  a  part  of  the  treatment, 
and  tolerating  to  the  limit  of  endurance,  with  a  resultant 
burn. 

Perfect  coaptation  must  be  secured  by  elastic  bands  of 
webbed  bandages,  and  the  surface  of  the  electrode  fits 
better  when  covered  with  a  well-moistened  pad  of  felt  or 
several  layers  of  lint  or  gamgee.  There  is  much  to  be  said 
in  favour  of  a  layer  of  clay  or  radioactive  earth  between  the 
electrode  and  the  skin.  Nothing  can  be  better  moulded  to 
the  part,  and  its  humidity  always  insures  good  conduction 
in  the  skin. 

The  Static  Machine. 

This  is  one  of  the  very  earliest  methods  of  employing 
electricity,  both  Benjamin  Franklin  and  John  Wesley 
having  interested  themselves  in  it.  It  differs  from  galvanism 
in  that  there  is  no  chemical  action,  but  the  current  is  entirely 
generated  by  friction  and  induction.  In  an  elementary 
type  of  machine  a  positive  charge  is  produced  by  friction 
on  a  revolving  plate  of  glass.  This  is  carried  to  collecting 
combs  near  one  of  the  poles  of  the  machine,  and  induces  a 
negative  charge  in  the  comb  and  a  positive  charge  in  the 
pole.  The  negative  charge  escapes  from  the  combs  of  the 
machine  as  a  static  breeze  or  brush  discharge,  which,  passing 
to  the  surface  of  the  plate,  neutralizes  the  positive  charge 
there,  and  leaves  the  plate  ready  to  be  recharged  by  friction 
at  another  part  of  its  revolution.  The  rubber  is  negatively 
charged  and  connected  with  the  other  pole  of  the  machine. 


384        MANUAL  OF  PHYSIO-THERAPEUTICS 

The  Wimshurst  is  perhaps  the  best-known  type  of  glass 
static  machine,  and  the  Toepler  and  the  Holtz  are  in  vogue 
in  the  States.  The  trouble  with  all  glass  machines  is, 
however,  the  difficulty  in  starting,  owing  to  moisture 
collecting  on  the  plates.  It  is  customary  to  enclose 
the  plates  in  a  glass  case,  and  keep  the  air  dry  by  means 
of  a  free  supply  of  chloride  of  calcium,  but  even  so 
we  know  few  people  in  this  country  who  have  not  dis- 
carded a  glass  machine  and  taken  to  those  constructed  of 
vulcanite. 

Vulcanite  plates  are  said  to  buckle,  but  the  writer  has  had 
a  ten-plate  in  steady  use  for  over  eleven  years,  and  this 
has  never  happened,  and  on  most  days  the  machine  can  be 
started  very  quickly,  always  being  kept  in  a  dry,  warm 
room  with  windows  closed,  except  in  summer,  and  a  good 
fire  going  in  winter.  Machines  of  this  type  are  made  by 
Gaiffe,  Dean,  Watson,  and  others.  Gaiffe  makes  the  plates 
22  inches  in  diameter  of  a  specially  prepared  vulcanite. 
They  are  run  at  a  speed  of  9,000  revolutions  per  minute, 
and  as  each  alternate  plate  goes  in  a  different  direction 
the  relative  speed  is  of  1,800  revolutions.  The  machine 
may  be  ten,  twelve,  or  twenty  plates;  the  main  axle  is 
driven  by  a  leather  belt  running  on  the  pulley  worked  by 
a  J  horse-power  motor.  The  axle  does  not  pass  through 
the  centre  of  the  plates,  but  on  the  side  away  from  the 
motor  and  below  the  plates.  From  it  small  driving  bands 
with  a  twist  on  them  pass  round  the  axle  of  the  plates, 
driving  each  a  different  way.  Tinsel  brushes  collect  the 
current  on  to  the  combs,  and  thence  it  passes  to  the  poles. 
We  have  not  used  Ley  den  jars  with  this  machine,  as  is 
quite  customary.  There  has  been  very  little  difficulty  in 
starting;  this  is  usually  done  by  getting  the  motor  going 
and  gradually  increasing  the  speed,  while  with  the  fingers 
of  each  hand  we  keep  up  friction  on  two  plates,  the  plates 
which  have  the  best  effect  varying  with  the  individual 
machine.  The  fingers  should  be  dusted  with  gold  size, 
which  makes  the  process  easier.  One  great  point  is  to  keep 
the  plates  clean  and  always  covered  with  a  sheet  or  water- 
proof cloth  when  not  in  use.  Periodically  they  should  be 
rubbed  up  with  methylated  spirits. 


HIGH-FREQUENCY  TREATMENT 


385 


The  base  of  the  machine  is  of  substantially  made  cast-iron 
frame  fixed  on  to  a  heavy  table  or  drawer  stand,  and  placed 
preferably  away  from  the  wall. 

An  insulated  platform  is  needed  for  use  along  with  the 
machine,  size  2  by  3  feet,  with  glass  legs  about  9  inches 


FIG.  203. — STATIC  MACHINE  WITH  Six  VULCANITE  PLATES. 

high,  kept  free  from  dust  and  moisture.  The  platform 
should  not  be  in  contact  with  any  other  object,  nor  near 
enough  to  lose  any  of  the  electric  charge  by  convection  or 
brush  discharge  to  a  neighbouring  object. 

The  platform  is  connected  to  the  machine,  as  a  rule,  by 
the  shepherd's  crook,  a  brass  rod  about  5  feet  long.     This 

25 


386       MANUAL  OF  PHYSIO-THERAPEUTICS 

is  hooked  over  the  prime  conductor  with  the  other  end 
resting  on  the  platform.  A  square  piece  of  metal  about 
|  inch  thick  usually  lies  on  the  top  of  the  platform,  and  the 
crook  is  allowed  to  come  into  contact  with  this.  A  stool 
is  placed  on  the  platform,  preferably  slotted  in  with  the 
back  legs  at  least,  to  prevent  the  patient  from  slipping  off 
backwards  and  having  a  nasty  fall. 

Over  the  patient's  head  is  suspended  the  crown,  either 
a  ring  of  brass  with  points  or  a  cup-shaped  piece  of  metal 
with  serrated  edges.  This  is  hung  to  a  lofty  ami  from  a 
stand  on  castors,  which  is  connected  by  a  chain  to  the  pole, 
not  connected  with  the  platform,  or  in  some  cases  merely 
earthed. 

If  Leyden  jars  are  used,  they  stand  on  the  table  which 
forms  the  base  of  the  machine,  and  when  in  use  are  con- 
nected with  the  poles  of  the  machine.  They  have  largely 
fallen  into  desuetude,  however,  and  if  they  are  not  very 
carefully  handled  the  patient  may  receive  a  pretty  severe 
shock,  at  times  receiving  the  whole  discharge  from  the 
two  jars.  A  concentrator  is  sometimes  employed,  and 
consists  in  a  brass  rod  mounted  on  a  metal  tripod,  and  so 
arranged  that  its  pointed  extremity  may  be  directed  towards 
any  part  of  the  patient.  A  chain  leads  to  it  from  one 
pole  of  the  machine  or  from  the  ground.  The  voltage  of 
the  machine  is  estimated  by  noting  the  length  of  the  spark 
which  passes  from  the  discharging  rods,  while  the  machine 
is  not  connected  with  any  other  object.  The  distance  across 
which  a  spark  will  flash  is  the  measure  of  the  electric 
potential.  A  spark  8  mm.  long  between  two  highly  polished 
balls  of,  say,  3  c.c.  diameter  represents  something  like 
20,000  volts  (Tousey). 

Positive  and  Negative  Poles. — The  poles  are  distinguish- 
able by  the  character  of  the  discharge.  It  is  noticeable 
that  when  the  discharging  rods  are  sufficiently  separated  to 
give  a  silent  discharge  there  is  a  bluish  colour  at  the  negative 
pole,  especially  if  the  room  be  darkened.  This  consists  of 
particles  of  electrified  air  radiating  in  lines  from  the  negative 
pole. 

Bright  thick  trunks  are  discerned  radiating  from  the 
positive  pole,  known  as  Greville's  trees.  They  are  straight 


HIGH-FREQUENCY  TREATMENT  387 

for  perhaps  £  inch,  and  then  split  into  crooked  branches, 
which  again  separate  into  twigs  radiating  towards  the 
negative  pole. 

If  the  poles  are  brought  together,  the  discharge  becomes 
sharp  and  crackling.  An  irregular  bright  line,  like  lightning 
in  a  picture  or  photo,  comes  from  the  negative  pole.  At 
a  short  distance  from  the  negative  pole  this  line  becomes 
very  bright  for  perhaps  |  inch.  If  we  bring  a  pointed 
electrode  (earthed)  towards  the  negative  pole,  we  see  fine 
blue  lines  discharging;  whilst  if  the  same  be  done  with  the 
positive,  we  see  a  point  of  light  on  the  electrode,  which 
disappears  when  the  proximity  is  so  great  as  to  cause  a 
discharge. 

We  have  described  above  how  the  patient  on  the  stool 
is  connected  with  the  machine  by  a  crook.  There  is  some 
difference  of  opinion  as  to  which  pole  the  crook  should  be 
attached  to.  Lewis  Jones  held  that  there  was  less  risk  of 
sparking  the  patient  if  it  is  hung  over  the  positive  pole 
and  the  negative  pole  is  earthed.  If  the  opposite  is  done, 
sparking  from  the  positive  readily  occurs,  and  may  hurt, 
or  at  any  rate  alarm,  the  patient.  The  negative  electric 
breeze  is  always  weaker  and  less  alarming  to  a  nervous 
patient. 

There  are  numerous  ways  of  using  the  static  machine: 

Simple  Charging. — In  this  no  crown  or  brush  is  used. 
The  crook  connected  with  the  positive  pole  rests  on  the 
insulated  stool  on  which  the  patient  is  seated,  the  effect 
being  enhanced  if  a  metal  sheet  is  placed  under  the  legs 
of  the, stool  and  the  patient  rests  his  feet  on  it.  The  patient 
merely  feels  a  slight  breeze,  and  the  sensation  as  a  wrhole 
is  agreeable. 

This  may  last  for  fifteen  or  twenty  minutes,  and  may  be 
elaborated  by  putting  the  crown,  or  wooden  disk  with  spike 
over  the  patient  connected  with  the  negative  pole.  This 
is  what  is  called  the  "  static  breeze."  If  the  shepherd's 
crook  is  connected  with  the  negative  pole  and  the  other 
end  lying  on  the  stool,  while  the  positive  pole  is  earthed  and 
the  disk  suspended  from  a  stand  uninsulated,  the  patient 
will  be  getting  a  positive  breeze — mutatis  mutandis,  he  will 
get  a  negative.  The  breeze,  of  course,  conies  from  the  disk 


388        MANUAL  OF  PHYSIO-THERAPEUTICS 

or  corona.  Alternatively  the  corona  may  be  connected 
with  the  positive  pole  by  a  chain,  the  earth  connection 
broken,  and  the  top  of  the  stand  made  of  a  glass  rod,  so  as 
to  complete  the  insulation.  This  makes  a  stronger  breeze 
Instead  of  being  applied  to  the  head,  or  along  with  it,  a 
breeze  may  be  applied  all  down  the  patient's  back  by  a 
specially  made  brush  or  toothed  electrode,  like  a  rake. 
This  is  very  pleasant  and  bracing,  and  helpful  to  neuras- 
thenics with  "  weak  backs  "  and  vague  neuralgic  pains  along 
the  posterior  spinal  roots. 

This  is  a  convective  brush  discharge.  Another  way  of 
doing  it,  requiring,  however,  the  time  of  the  attendant,  is 
by  means  of  a  fibre  brush  or  wire  toothed  disk  insulated 
from  the  person  manipulating  it.  Instead  of  a  brush, 
in  very  local  affections  a  mere  point  may  be  used.  Good 
results  are  obtained  in  neuralgia  and  nervous  headaches. 

If  metal  or  wire  points  are  used,  we  call  it  the  spray 
discharge. 

Sparking  or  disruptive  discharge  is  arranged  in  much  the 
same  way,  but  a  metal  ball  electrode  used  in  place  of  the 
point  or  brush.  The  effect  is  much  sharper  and  more  pain- 
ful, and  requires  care  in  handling.  The  larger  the  ball,  the 
sharper  the  spark;  the  strength  is  also  dependent  on  the 
rate  of  the  revolutions  of  the  plates,  but  a  handy  way  of 
"  watering  down  "  the  charge  is  for  the  operator  to  place 
his  boot  on  the  platform  so  as  to  divide  the  charge  with 
the  patient. 

In  order  to  localize  the  discharge  for  some  specially 
painful  point,  a  metal  disk  may  be  secured  on  the  part  with 
strapping  or  a  piece  of  tape  threaded  through  slots  in  the 
side.  Bony  points  must  be  avoided,  or  the  pain  may  be 
•severe. 

Alternatively  Tripier's  electrode  may  be  used — a  semi- 
circle of  glass  rod  with  a  sliding  adjustment,  so  that  the 
distance  between  two  balls  may  be  regulated  to  a  nicety. 
The  electrode  is  then  kept  into  contact  with  the  part  treated 
by  means  of  a  leather-covered  electrode.  A  roller  electrode 
is  sometimes  used,  sparks  passing  from  the  whole  length  of 
the  roller,  provided  it  is  not  in  contact  with  the  skin.  The 
roller  may  be  simply  run  over  the  surface  of  the  patient's 


HIGH-FREQUENCY  TREATMENT  389 

clothes,  and  the  thicker  they  are,  the  greater  the  stimula- 
tion. Here,  again,  the  operator  should  hold  the  earthed 
electrode  by  an  insulated  handle  and  dilute  the  charge  with 
his  foot  on  the  insulated  stool. 

Static  Wave  Currents. — This  is  a  variety  from  simple 
charging.  The  patient  is  connected  up  in  the  same  way, 
but  the  negative  conductor  earthed.  The  two  prime  con- 
ductors of  the  machine  are  then  brought  close  together, 
so  that  a  stream  of  sparks  passes  between  them.  Positive 
conductor  and  patient  are  both  rapidly  charged.  If  the 
conductors  are  separated,  the  strength  of  the  current  is 
increased. 

An  important  point  arises  in  connection  with  earthing 
one  prime  conductor  as  well  as  the  electrodes  in  use  through 
the  operator's  feet,  as  is  often  done.  Most  machines  are 
more  powerful  in  their  discharge  when  one  set  of  conductors 
is  earthed — as  they  are  connected  with  an  inexhaustible 
supply  of  electricity — in  the  earth.  A  second  point  is  that 
the  person  handling  the  electrode,  as  in  the  convective 
discharge,  is  protected  against  shocks,  for  he  is  at  the  same 
electrical  pressure  as  the  electrodes  he  is  handling — the 
zero  point  of  earth  pressure. 


lonization. 

lonization,  or  cataphoresis,  or  iontophoresis,  as  it  is 
sometimes  called,  is  a  method  of  utilizing  the  power  which 
electric  currents  possess  for  setting  the  various  constituents 
of  a  saline  solution  in  orderly  motion  in  a  definite  direction. 
For  all  practical  purposes  the  human  body  may  be  regarded 
as  a  saline  solution,  and  obeying  the  same  laws  as  regards 
conductivity. 

Ionic  medication  is  the  introduction  of  various  drugs 
into  the  superficial  structures  of  the  body  through  the  skin 
and  underlying  tissues,  and  setting  up  electro-chemical 
interchange  in  the  deeper  structures  such  as  joints  and 
nerves. 

Distilled  water  is  a  very  bad  conductor  of  electricity, 
rain  water  a  better  conductor,  but  if  an  acid  or  salt  be 


390       MANUAL  OF  PHYSIO-THERAPEUTICS 

added  the  conductivity  is  very  materially  increased,  and  the 
solution  is  then  called  an  electrolyte. 

Practically  all  soluble  chemical  substances  undergo  a 
change  in  their  constitution  when  the  electrical  current 
passes,  and  their  constituents  migrate  according  to  certain 
fixed  laws  which  we  shall  give  below  in  detail.  In  the 
commercial  process  of  electroplating,  for  instance,  the 
silver  atom  Ag  migrates  to  the  kathode  to  which  the  article 
to  be  plated  is  attached,  while  the  acid  moves  towards  the 
positive  pole.  Such  movements  are  based  on  the  elementary 
principle  that  like  repels  like,  and  vice  versa. 

An  ion  is  an  electrically  charged  chemical  atom.  The 
Swedish  chemist  Arrhenius  held  that  the  action  of  water 
on  an  electrolyte  was  one  of  dissociation,  the  molecules  of 
the  salt  being  split  up  by  the  solvent,  and  this  is  probably 
true  if  the  solution  be  diluted  to  infinity. 

The  electrolytes  spoken  of  above  which  conduct  the 
electricity  contain  a  number  of  neutral  molecules,  free 
positive  and  free  negative  ions.  When  the  electric  current 
is  passed  a  disturbance  occurs  in  the  solution;  numerous 
positively  charged  and  negatively  charged  ions  are  gathered 
around  the  positive  pole  (anode),  and  also  the  kathode. 

The  moment  the  current  begins  to  flow,  the  positive  ions 
in  the  region  of  the  anode  and  the  negatively  charged  ions 
near  the  kathode  follow  the  universal  electrical  law  that 
like  repels  like,  and  vice  versa.  The  negative  ions  trvael 
away  to  the  anode  and  the  positive  ions  to  the  kathode. 
The  speed  with  which  this  adjustment  takes  place  will  vary 
with  the  concentration  of  the  solution  and  the  proportion  of 
basis  radicles  to  the  acid  or  hydroxyl  radicles. 

A  simple  experiment  will  help  to  make  clear  the  process 
and  convince  the  observer  that  penetration  of  tissues  in 
the  human  body  does  take  place.  Take  a  piece  of  steak 
and  plunge  a  copper  wire  into  it  which  is  connected  with 
the  positive  pole.  A  little  way  from  the  copper  wire  plunge 
a  platinum  wire  into  the  steak  connected  with  the  negative- 
pole.  NOAV  pass  a  current  of,  say,  20  milliamperes,  and  a 
streak  of  green  oxychloride  of  copper  will  be  found  starting 
away  from  the  copper  electrode  and  diffusing  through  the 
beef  to  the  negative  electrode. 


HIGH-FREQUENCY  TREATMENT  391 

The  beginner  is  sometimes  rather  confused  by  the  fact 
that  ions  move  with  no  regard  to  the  flow  of  the  current — 
they  often  move  against  it,  indeed.  As  is  well  known,  the 
current  usually  passes  in  the  external  circuit  from  the 
positive  pole  to  the  negative.  But  when  passing  through 
an  electrolyte  the  acid  radicles  are  set  free  around  the 
positive  pole,  travelling  in  the  opposite  direction  to  the 
current,  while  the  basis  metallic  radicles  are  set  free  around 
the  negative  pole  and  repelled  by  the  positive  pole,  and 
travel  in  the  same  direction  as  the  current.  Ions  passing 
towards  the  negative  pole,  being  positively  charged,  are 
called  kations,  and  those  which  travel  towards  the  positive 
pole  are  negatively  charged  and  called  anions. 

Metallic  and  basic  radicles,  being  themselves  positively 
charged,  should  be  connected  with  the  positive  pole  when 
it  is  desired  to  introduce  them  into  the  human  body — the 
most  common  solutions  being  f  cocaine  hydrochlorate, 
sulphates  of  magnesium,  zinc  quinine,  etc.  Here  the  metallic 
ions  penetrate  the  tissues  and  the  sulphates  remain  around 
the  positive  pole. 

Acid  radicles  are  negatively  charged,  and  should  be 
introduced  by  the  negative  pole,  as  they  travel  towards  the 
positive.  Such  are  potassium  iodide,  chloride  of  sodium, 
salicylate  of  soda.  The  acid  radicles  penetrate  the  tissues, 
and  the  metallic  radicles  remain  around  the  negative, 
pole. 

A  rule  may  thus  be  formulated  for  procedure  which  it  is 
very  important  and  not  always  found  easy  to  bear  in  mind: 
The  ion  we  desire  to  introduce  into  the  tissues  must  be  con- 
nected to  the  pole  having  the  same  electric  charge  as  itself. 
For  instance,  in  treating  a  sciatica  with  a  pad  on  the  patient's 
thigh  or  buttock,  we  must  remember  to  have  the  pad 
soaked  in,  say,  2  per  cent,  of  iodide  of  potash  connected  with 
the  negative  pole,  while  the  foot  is  placed  in  a  basin  of 
water  in  which  lies  the  positive  pole. 

In  treating  warts  on  the  hand  with  magnesium  sulphate, 
\ve  connect  the  pad  over  the  wart  with  the  positive  pole, 
while  the  negative  pole  is  connected  with  a  pad  or  armlet 
round  the  wrist. 

The    strength    of    the    solutions    employed    varies    from 


392  MANUAL  OF  PHYSIO-THERAPEUTICS 

1  to  3  per  cent.,  but  should  not  be  stronger,  as  otherwise 
the  treatment  becomes  painful. 

Stock  solutions  should  be  kept  of  4  per  cent.,  which  can 
be  diluted  if  desired.  Soloids  are  prepared  which  make  a 
solution  of  1  per  cent,  when  dissolved  in  an  ounce  of  water. 
The  desirability  of  using  pure — preferably  distilled — water 
for  the  solvent  becomes  obvious  when  we  remember  how 
delicate  the  solution  is  we  are  dealing  with.  In  practice  there 
is  no  objection  to  wetting  the  inactive  pole  with  normal 
saline  solution,  as  the  current  is  the  more  easily  carried. 

A  further  rule  to  remember  is  that  the  effect  of  the  ioniza- 
tion  depends  on  the  speed  of  penetration  of  the  tissues,  which 
varies  directly  with  the  milliamperage  passing. 

As  we  have  said  previously,  the  charge  in  metals  and 
alkaloids  is  a  positive  and  in  non-metals  a  negative  one. 
Let  us  assume  that  we  are  dealing  with  a  solution  of  chloride 
of  sodium,  or  common  salt,  and  the  electrodes  are  adjusted 
and  current  passed.  The  halogen  elements  carry  a  negative 
charge  and  move  against  the  current,  while  the  metal  is 
positive  and  moves  with  it.  The  condition  before  the 
current  passes  may  be  figured  as  below: 

Cl          01          Cl  Cl          Cl          Cl 

Na         Na         Na  Na         Na         Na 

After  the  current  has  passed  it  is — 

Cl      Cl      Cl     Cl      Cl      Cl 

Na     Na     Na     Na        Na     Na 

The  sodium  ions  here  move  with  the  current  and  have 
accumulated  at  the  negative  pole,  while  the  chlorine  has 
moved  against  it  and  accumulated  at  the  positive  pole. 
If  we  are  using  iodide  of  potash  on  a  rheumatic  knee  or 
elbow,  the  following  would  take  place : 

Anode.  Body.  Kathode. 

K    K  Na     Na     Na  K    K 

,11  Cl      Cl      Cl  II 

Before  the  current  is  turned  on: 


K 

I     I     Cl 


K  Na     Na     Na         K    K 

Cl  Cl      Cl      Cl 


HIGH-FREQUENCY  TREATMENT          393 

The  ions  gradually  replace  the  normal  constituents  of  the 
part. 

Supposing  we  are  going  to  introduce  zinc  salts  by  cata- 
phoresis,  we  apply  a  moist  pad  impregnated  with  the  salt 
to  the  skin,  and  superimpose  on  it  the  electrode  leading 
from  the  positive  pole  of  the  switchboard  or  the  battery, 
whichever  we  are  using.  The  electrode  should  be  of  zinc. 
As  the  current  flows  the  zinc  ions,  constantly  renewed,  pass 
down  to  the  deeper  tissues.  The  similarity  of  the  base 
metal  is  important  to  avoid  contamination.  If  quinine 
or  salicylic  acid  be  used,  the  lint  or  cotton-wool  should  be 
kept  well  moistened  with  the  solution,  or,  better,  the  ad- 
ministration should  be  conducted  with  a  glass  reservoir 
electrode  covered  with  a  membranous  diaphragm.  If  this 
be  not  used,  then  the  electrode  should  be  of  carbon  or 
platinum.  Generally  speaking,  the  switchboard,  when 
connected  with  the  main,  is  greatly  to  be  preferred  to  the 
use  of  a  battery  of,  say,  24  cells,  as  with  the  former  we 
gradually  increase  the  current  by  cutting  out  resistance  in 
a  rheostat,  while  with  the  battery  we  have  to  be  constantly 
putting  on  fresh  cells,  and  the  change  from  one  stud  to 
another  is  quickly  noticed  by  the  patient,  to  whom  it 
causes  considerable  pain  and  discomfort  if  the  current  be 
fairly  strong. 

Care  taken  with  details  of  the  procedure  well  repays  the 
operator.  Conducting  cords  should  be  of  copper  flex,  so 
as  to  avoid  a  bad  contact.  This  would,  of  course,  cause 
the  patient  discomfort  due  to  minor  shocks.  The  very 
slight  silk-covered  cords  supplied  with  cheap  batteries  -are 
to  be  avoided  for  this  reason. 

As  regards  electrodes.,  these  need  not  be  large  in  size,  and 
are  best  made  of  sheet  metal.  The  chain-mail  type  are  not 
to  be  recommended.  If  adequate  care  be  taken  in  adjusting 
the  material  lying  between  the  electrode  and  skin,  an 
electrode  with  a  diameter  of  2  inches  will  give  an  even 
diffusion  of  current  over  an  area  measuring  5  inches  each 
way.  Few  cases  will  require  more  than  this.  Aluminium 
is  a  veiy  suitable  metal  to  employ.  The  binding-screw 
should  be  fastened  to  it,  and  preferably  at  one  side  rather 
than  in  the  centre  of  the  upper  surface.  Small  holes  in  the 


394        MANUAL  OF  PHYSIO-THERAPEUTICS 

periphery  are  convenient  for  stitching  felt  or  other  fabric 
to  the  plates.  The  felt  insures  a  good  diffusion  of  current 
and  takes  up  the  products  of  secondary  reactions  occurring 
at  the  surface  of  the  metal.  Before  using,  the  felt  should 
be  soaked  for  a  long  time  in  hot  water  with  some  soda  or 
ammonia  in  it,  in  order  to  remove  the  natural  oily  matter 
which  is  invariably  present  when  the  fabric  is  new.  Below 


FIG.  204. — HANDLE  WITH  COPPER  ELECTRODE. 

the  felt  is  placed  the  electrolytic  layer  proper,  which  is  of 
lint  or  gamgee  tissue,  four,  eight,  or  even  sixteen  layers 
thick.  While  the  felt  is  always  cut  larger  than  the  metal, 
the  cotton  layer  should  be  cut  larger  still.  This  latter  will 
act  as  a  reservoir  of  the  electrolyte,  from  which  the  ions 
pass  into  the  skin  once  the  current  is  switched  on.  If  the 
electrode  is  of  the  same  metal  as  the  base  of  the  salt  used, 
such  as  zinc  01  copper  and  zinc  sulphate  and  copper  sulphate, 


FIG.  205. — COPPER  AND  ZINC  ELECTRODES. 

little  in  the  way  of  a  reservoir  is  needed,  as  the  metal  is  so 
constantly  renewed  from  the  electrode.  Few  layers  of 
fabric  are  then  employed.  Lint  is  quite  suitable  for  small 
joints,  such  as  those  of  the  fingers  or  toes,  but  for  a  knee 
or  elbow  gamgee  is  best. 

Where  practicable,  it  is  desirable  to  have  the  electrodes 
of  the  same  metal  as  the  base  of  the  salt  used;  but  if  we 
are  using  KI  or  sodium  salicylate,  then  it  is  highly  desirable' 


HIGH-FREQUENCY  TREATMENT  395 

to  use  several  layers  of  lint  or  gamgee,  to  prevent  the  ions 
of  the  metal  electrode  reaching  the  skin. 

In  treating  large  areas  and  conditions  such  as  sciatica 
and  rheumatic  trouble,  big  currents  of  100  or  more  milli- 
amperes  may  be  called  for.  It  is  essential  in  such  cases 
to  use  large  electrodes  of  flexible  material  easily  appliable 
to  the  parts.  A  heavy  current  with  a  small  electrode  will 
easily  produce  a  blister  or  painful  burn  difficult  to  heal. 
The  most  flexible  electrode  we  can  get  is,  of  course,  water, 
and  there  is  therefore  a  great  deal  to  be  said  for  using  the 
pots  of  a  Schnee  bath  in  electrolysis,  as  has  been  our  practice 
for  a  number  of  years.  The  only  irritation  the  patient 
suffers  here  is  usually  at  the  water-line,  and  this  may  be 
largely  prevented  by  putting  a  layer  of  liquid  paraffin  over 
the  surface  of  the  water,  though,  of  course,  this  adds  to  the 
expense  of  the  treatment.  On  the  other  hand,  with  large 
areas  a  very  considerable  amount  of  gamgee  tissue  and 
lint  may  be  consumed  at  each  treatment  if  wre  do  not  use 
the  Schnee  cells.  By  this  method  currents  of  considerable 
intensity  will  be  evenly  distributed  over  the  part,  as  the 
whole  of  the  solution  contained  constitutes  the  electrode. 

It  is  hardly  necessary  to  emphasize  the  necessity  in  such 
cases  to  be  unusually  careful  with  all  connections,  as  should 
an  electric  cord  conductor  get  a  rift  suddenly,  the  shock 
to  the  patient  may  be  both  very  painful  and  damaging. 
The  connecting  wire  should  preferably  be  soldered  to  the 
electrode,  and  such  electrodes,  when  used  for  lying  or 
sitting  on,  of  course,  have  the  obvious  advantage  that  the 
patient  is  not  sitting  on  a  projecting  screw,  nut,  or  stud. 

Preparation  of  the  skin  is  important  before  ioiiization; 
it  should  be  washed  with  soap  and  water,  and  ether  or  alcohol 
wiped  over  it  before  beginning  to  remove  all  grease.  Acne 
spots,  etc.,  must  be  carefully  covered  with  wool  and  col- 
lodion. The  removal  of  rings,  etc.,  is  essential,  and  must 
be  invariably  carried  out.  One  of  us  recalls  a  very  painful 
burn  inflicted  through  neglect  of  this  by  a  careless  attendant. 
Burns  so  inflicted  are  very  slow  to  heal. 

t^The  sensations  of  the  patient  if  the  treatment  be  properly 
given  are  slight.  The  current  is  gradually  turned  on,  several 
minutes  being  taken  to  reach  a  maximum.  The  same 


396        MANUAL  OF  PHYSIO-THERAPEUTICS 

procedure  is  adopted  in  finishing,  the  current  being  gradually 
reduced. 

Unequal  density  of  current  causes  pain,  and  a,  blister 
may  form.  The  galvanometer  must  be  carefully  observed, 
and  it  the  current  registered  suddenly  rises  without  any 
adjustment  by  the  administrator  it  may  be  due  to  a  breaking 
down  of  the  skin  resistance,  and  cause  a  burn  if  the  current 
be  not  reduced. 

Half  an  hour  is  usually  long  enough  for  a  seance,  unless 
in  special  cases. 

Success  will  vary  with  the  care  of  the  administration  and 
the  size  of  the  electrodes,  as  large  sizes  as  possible  being 
always  used. 

Zinc  lonization. — This  is  used  for  the  treatment  of  rodent 
ulcer,  the  zinc  sulphate  salt  being  employed.  A  pad  of 
lint  containing  1  per  cent,  solution  is  placed  over  the  area  of 
the  ulcer.  A  zinc  electrode,  also  padded  with  lint  soaked 
in  the  solution,  is  connected  with  the  positive  pole  and 
applied  over  the  area  affected. 

The  indifferent  electrode  is  applied  at  some  convenient 
spot.  If  the  ulcer  be  on  the  surface  of  the  face,  the  in- 
different electrode  is  applied  at  the  back  of  the  neck. 

The  strength  of  the  current  will  vary  with  the  size  of  the 
electrode,  allowing  2  milliamperes  for  each  square  centimetre 
of  the  electrode.  This  is  applied  for  from  ten  to  fifteen 
'minutes.  Most  patients  can  bear  this  current  quite  well, 
but  in  most  cases  it  is  desirable  to  use  a  little  cocaine, 
introduced  also  by  cataphoresis.  Lint  is  dipped  into  1  per 
cent,  cocaine  solution  and  the  current  passed  for  a  few 
minutes,  the  same  electrode  being  used  as  for  the  zinc 
ionization.  The  penetration  of  the  zinc  ions  gives  the 
rodent  ulcer  a  milky-white  appearance  on  the  surface,  which 
fades  gradually. 

Copper  lonization  is  used  for  ringworm,  the  best  salt 
being  copper  sulphate,  1  per  cent,  solution.  A  pure  copper 
electrode  is  used  with  the  positive  pole.  It  is  also  used 
in  lupus  erythematosus  and  in  rodent  ulcer. 

Cocaine  is  used  as  described  above,  and  is  of  service  in 
some  varieties  of  neuralgia.  It  is  probably  the  safest  way 
of  using  cocaine  to  prevent  a  habit;  the  patient  need  not 


HIGH-FREQUENCY  TREATMENT  397 

know  what  is  being  used,  and  the  paraphernalia  employed 
will  put  the  idea  of  personal  use  out  of  his  head  any  way. 

Lithium  is  used  for  gout,  rheumatoid,  and  synovitis  of 
rheumatic  origin.  A  good  combination  is  lithium  on  the 
positive  pole  and  iodine  on  the  negative. 

Magnesium. — Multiple  warts  on  the  hands  can  be  easily 
removed  by  the  use  of  magnesium  ions.  These  are  obtained 
from  a  1  per  cent,  solution  of  magnesium  sulphate,  using 
a  carbon  electrode  with  a  pad  of  lint  to  hold  the  solution. 
A  magnesium  metal  electrode  is  advantageous. 

Salicylic  Acid. — These  ions  are  useful  in  treating  rheu- 
matism, sciatica,  and  neuritis.  A  large  pad  with  1  per  cent, 
is  used  attached  to  the  negative  pole  on  a  carbon  electrode. 
If  used  for  arm  or  knee,  the  hand  or  foot  is  placed  in  a 
porcelain  bath  fitted  with  the  positive  electrode  for  con- 
venience. 

Sodium  Chloride. — Chloiine  ions  promote  the  absorption 
of  newly  formed  fibrous  tissue,  and  have  given  good  results 
in  cicatricial  contractions.  Potassium  iodide  is  used  for 
iodine  ions,  with  or  without  iodine  painted  over  the  part 
treated,  and  gives  good  results  in  chronic  rheumatic  cases. 
Quinine  has  been  used  (with  the  positive  pole)  with  success 
in  neuralgia. 

The  Bergonie'  Treatment. 

The  underlying  principle  in  this  treatment  is  the  electrical 
stimulation  of  the  body  muscles  to  a  therapeutic  end, 
simulating  exercise. 

It  is  a  well-known  fact  that  the  proper  use  of  any  muscle 
or  organ  increases  the  vitality  peculiar  to  that  muscle  or 
organ,  at  the  same  time  favourably  influencing  the  vitality  of 
the  whole  body. 

This  has  been  specially  demonstrated  as  regards  the 
muscular  system,  which  is  known  to  be  developed  best  by 
graduated  general  exercises  (see  section  on  Physical  Train- 
ing), which  at  the  same  time  prevents  defective  combustion 
of  the  metabolic  products.  By  means  of  the  Bergonie 
apparatus  the  muscles  are  caused  to  contract  some  hundreds 
of  times  per  minute,  and  to  do  so  without  giving  rise  to 
any  undue  fatigue. 


398         MANUAL  OF  PHYSIO-THERAPEUTICS 

The  special  coil  employed  in  this  machine  is  of  a  coarse 
faradic  type,  with  a  break  of  special  construction,  as  shown 
in  Fig.  206.  The  special  points  about  the  break  are  that  it 
emits  a  purely  musical  note,  without  variation  of  pitch  or 
intermittency ;  the  interruptions  are  about  50  per  second, 
and  there  must  be  no  sparking  between  the  screw  and  the 
trembler,  or  the  treatment  will  be  painful  and  cause  dis- 
comfort to  the  patient.  The  correct  and  incorrect  wave 
tracings  are  shown  below,  taken  with  a  Blondel  oscillometer. 
Fig.  206  shows  the  correct  form  of  undulation,  while  Fig.  207 
shows  the  undulations  of  a  badly  adjusted  interrupter. 


Ebonite 


FIG.  206. 

The  former,  being  irregular,  causes  pain  which  is  quite 
insupportable. 

The  Coil  and  the  break  are  mounted  on  a  solid  marble 
base  containing  a  large  condenser,  which  is  connected  across 
the  point  of  the  interrupter — that  is,  in  contact  with  the 
platinum  contact  pillar  and  the  pillar  supporting  the  contact 
spring.  It  may  be  either  worked  from  accumulators  or 
the  direct-current  supply  main,  and  requires  roughly 
60  watts- — i.e.,  2-5  amperes  at  24  volts.  The  intensity  of 
the  current  in  the  secondary  is  roughly  500  milliamperes. 

The  Metronome  (Rhythmic  Reverser). — Being  provided 
with  a  suitable  faradic  current,  we  have  to  pass  it  through 
a  metronome  or  rhythmic  reverser  introduced  by  Bergonie. 
By  means  of  it  we  are  able  to  avoid  fatigue  and  exhaustion 
of  the  muscles.  It  gives  the  necessary  alternations  of 


HIGH-FREQUENCY  TREATMENT 


399 


excitement  and.  repose  in  the  muscle  fibres,  just  as  it  regu- 
lates the  cadence  of  music.  At  every  heart-beat  the  current 
is  reversed,  which  makes  the  muscular  stimulation  painless 
and  pleasant.  The  oscillograph  shows  the  undulations  of 
the  faradic  current  to  be  asymmetrical.  The  excitation  of 


2  re 


JJJJ^JJJJJJJ'JJJJT 

FlG.    207. — OSCILLOGRAM   OF   THE   CORRECT   WAVE   FORM. 

a  muscle  is  quite  different,  according  as  we  use  one  or  the 
other  electrode.  In  order  to  obtain  a  painless  and  pleasant 
contraction  it  is  necessary  at  each  break  to  reverse  the 
poles  when  the  asymmetry  disappears.  It  has  been  found 
that  regulating  the  metronome  to  one  double  beat  per 


FIG.  208. — INCORRECT  FORM  OF  UNDULATIONS  FROM  AN  UNSUITABLE 
OR  BADLY  ADJUSTED  INTERRUPTER,  TAKEN  WITH  BLONDEL'S 
OSCILLOMETER. 


second  gives  the  best  results.  By  adjusting  the  mercury 
this  may  be  divided  into  four  equal  periods.  During  the 
first  quarter  of  a  second  the  muscle  is  in  repose;  during 
the  next  it  contracts  from  the  stimulation  of  one  pole; 
during  the  third  quarter  of  a  second  it  is  again  at  rest, 


400        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  during  the  final  half  a  second  it  again  contracts  from 
the  stimulation  of  the  opposite  pole.  There  are  thus  two 
intervals  of  repose  with  two  intervals  of  excitation;  the 
stimulations  are  of  unequal  intensity,  though  of  equal 
duration,  the  sequence  being — repose,  strong  contraction; 
repose,  weak  contraction.  There  is  therefore  a  distinct 
resemblance  to  the  variations  of  mechanical  energy  in  a 
gymnastic  exercise. 

If  pain,  fatigue,  and  exhaustion  of  the  muscle  are  to  be 
avoided,  it  is  necessary  to  avoid  producing  the  condition 
known  as  tetanus.  Each  electrically  executed  contraction 
must  be  followed  by  a  rest  of  equal  duration,  and  if  proper 
rhythm  be  maintained  this  is  just  what  happens.  The 
metronome,  by  rhythmically  inverting  the  current,  enables 
one  to  attain  almost  perfect  regularity  and  to  avoid  muscle 
fatigue  and  pain.  A  patient  usually  finds  two  contractions 
per  second  of  the  muscle  or  120  per  minute  very  comfortable, 
and  if  this  be  kept  up  for  forty  minutes  to  an  hour  it  is  hardly 
necessary  to  say  that  there  is  a  great  output  of  muscular 
energy  and  tissue  combustion  going  on. 

The  switchboard  of  this  apparatus  is  extensive  in  area 
and  looks  rather  complicated — more  so  than  it  really  is 
when  we  come  to  examine  and  use  it.  There  are  two  points 
of  entry  for  the  current,  and  a  hot-wire  meter  graduated 
from  zero  to  100  milliamperes ;  it  is  also  usual  to  have  an 
automatic  clock,  by  means  of  which  the  duration  of  the 
treatment  may  be  regulated  automatically.  There  is  a 
general  rheostat  controlling  the  entire  current  to  the  patient, 
with  three  rows  of  resistance — one  with  100  ohms,  one 
with  1,000  ohms,  and  one  with  10,000  ohms.  The  polarity 
of  the  electrodes  is  controlled  by  twelve  knife  switches. 
If  the  switch  is  turned  up,  the  current  is  positive;  if  turned 
down,  negative.  In  addition  to  the  general  rheostat,  there 
are  twelve  minor  rheostats  in  series  with  each  circuit  and 
controlling  the  current  therein,  thus  regulating  the  amount 
of  current  in  arm,  leg,  back,  abdomen,  etc.  These  are 
simply  sliding  resistances  with  20  stops  in  each,  each  stop 
being  equal  to  100  ohms.  The  terminals  for  each  circuit 
are  grouped  into  a  special  junction-box,  from  which  a 
twelve-way  cable  leaves  and  terminates  in  twelve-way 


HIGH-FREQUENCY  TREATMENT 


401 


plugs,  which  is  inserted  into  a  corresponding  socket  attached 
to  the  special  chair  figured  and  described  below. 

Method  of  Application. — The  patient  wears  some  clothing 
which  permits  of  free  access  to  the  body  surface,  which  can 
be  easily  slipped  off  if  need  be,  such  as  a  sheet  "with  arm- 


FIG.  209. — EERGONIE  SWITCHBOARD. 

holes  or  a  light  dressing-gown  reversed,  with  the  buttons 
at  the  back.  This  permits  of  contact  with  the  back  and 
seat  of  the  patient.  The  patient  reclines  comfortably  in 
the  chair,  and  four  more  pads  are  placed  on  the  surface  of 
the  body,  two  on  the  abdomen  and  one  on  each  thigh.  The 

aft 


402        MANUAL  .OF  PHYSIO  THERAPEUTICS 

electrodes  are  then  adapted  to'  these.  They  are  kept  in 
apposition  by  the  use  of  sandbags  filled  not  too  full,  so 
that  they  can  readily  adapt  themselves  to  the  surfaces  of 
the  body. 

As  regards  the  patient's  sensations,  he  feels  at  first  some- 
thing like  a  surge  of  blood  in  the  parts  treated,  then  pulsa- 
tions begin  and  the  muscles  contract,  raising  the  sandbags 
rhythmically  in  time  with  the  metronome. 


FIG.  210.-  BEKGOXIK  ("HAIE. 

The  general  rheostat  should  be  cut  out  bit  by  bit,  and 
the  various  circuit  rheostats  so  adjusted  that  the  current 
in  each  circuit  is  such  as  to  produce  equal  contraction  in 
the  various  muscles;  after  that  the  general  rheostat  can 
be  further  cut  out  to  suit  the  patient,  when  all  the  muscles 
will  be  seen  to  contract  rhythmically  along  with  the  metro- 
nome without  any  painful  sensation  to  the  patient. 

Electrodes. — The  aim  of  the  treatment  being  to  excite 
as  many  muscles  as  possible,  we  have  to  make  use  of  both 
a  considerable  number  of  electrodes  and  of  those  with  large 


HIGH-FREQUENCY  TREATMENT  403 

surface  area.  The  patient  somewhat  resembles  the  knight 
of  old,  being  enveloped  in  metal.  The  electrodes  are  of 
two  types,  fixed  and  movable.  The  fixed  electrodes  form 
the  back  and  seat  of  the  chair,  which  are  covered  by  four 
separate  plates  or  sheets  of  brass  or  aluminium — one  for 
each  buttock  and  one  for  each  side  of  the  back.  They  may 
be  used  bare,  having  previously  been  warmed  up  in  cold 
weather,  or,  better,  should  be  overlaid  with  towels  wrung 
out  of  hot  water.  The  movable  electrodes  of  the  same 
material  are  semicylindrical  in  pattern.  They  are  placed 
on  the  thighs,  the  calves  of  the  legs,  the  abdomen  and  fore- 
arms. Thus  no  less  than  twelve  electrodes  are  used,  having 
a  joint  surface  of  10,000  square  centimetres. 

Excepting  the  abdominal  electrode,  they  are  all  sym- 
metrical in  pairs;  the  polarity  of  the  current  in  any  region 
may  thus  be  very  readily  changed.  The  electric  resistances 
of  the  patients  vary,  and  may  be  as  low  as  200  ohms. 

For  fixing  the  electrodes  rubber  bands  have  been  used, 
but  quickly  waste,  and  the  most  effectual  way  is  to  employ 
sandbags.  They  not  only  maintain  good  contact,  but 
increase  the  work  done  by  the  violent  rhythmic  contractions 
of  the  muscles. 

Weights  up  to  2  hundredweight  have  been  used  with 
good  results,  as  during  faradization  it  is  lifted  without 
fatigue  or  sensation  of  discomfort.  Patients  often,  indeed, 
prefer  heavier  weights,  as  the  contact  is  more  perfect. 

Duration  and  Frequency  of  the  Stances. — The  time  should 
be  gradually  increase d— from  twenty  minutes  for  the  first 
time  will  be  usually  enough,  then  quickly  increased  to  half 
an  hour,  then  up  to  an  hour,  and  if  necessary  this  may  be 
given  twice  a  day. 

If  possible,  the  patient  should  be  looking  out  of  a  window, 
with  a  view  of  some  objects  of  interest  to  distract  his  or 
her  attention,  or  have  someone  sitting  by  who  can  talk 
amusingly  and  prevent  boredom.  Otherwise  the  treatment 
is  a  little  trying  from  its  duration.  The  present  type  of 
apparatus  is  quite  silent,  and  the  rather  irritating  tick-tock 
of  the  metronome  done  away  with. 

This  treatment  has  been  evolved  from  various  attempts 
to  apply  faradism  or  interrupted  galvanism  to  large  areas 


404        MANUAL  OF  PHYSIO -THERAPEUTICS 

of  the  body  surface  at  once,  and  its  use  is  mainly  for  those 
patients  whose  disorders  would  yield  to  the  faradic  current 
when  applied  in  definite  ways  and  under  definite  conditions. 
But  it  was  not  until  this  apparatus  was  introduced  that  such 
treatments  became  at  all  possible ;  for  despite  the  fact  that 
attempts  had  been  made  to  reduce  the  body-weight  by 
means  of  electricity,  the  process  had  been  so  tedious  and 
accompanied  by  such  discomfort  that  it  had  to  be 
given  up. 

Now,  however,  we  have  an  ideal  circulatory  stimulant, 
and  one  that  is  unaccompanied  by  any  serious  disadvantage. 
The  worst  that  can  be  said  about  it  is  the  duration  of  the 
treatment,  both  per  seance  and  for  the  course.  Consider- 
able time  elapses  in  cases  before  very  material  improvement 
is  noticeable  sometimes.  In  most  cases  a  drop  in  weight 
is  noted  from  the  start,  however. 

Few  people  know  how  to  exercise  their  muscles  properly, 
so  that  they  remain  largely  unused  and  partly  degenerate, 
and  become  a  sort  of  backwater  for  morbid  waste  products 
of  deficient  metabolism.  It  is  here  that  the  Bergonie  system 
does  most  good.  Muscular  pains  and  stiffness  may  yield 
to  two  or  three  treatments. 

In  undergoing  obesity  treatment  a  patient  may  lift 
seventy  times  a  minute  1  hundredweight  or  more  of  weight, 
and  rise  as  fresh  as  from  a  good  sleep.  Thus  great  advan- 
tages are  held  out  to  those  patients  whose  increasing 
corpulency  makes  their  life  burdensome,  as  well  as  to  those 
of  the  bilious  lymphatic  type,  whose  muscles  are  firmed  up 
and  metabolism  stimulated  by  rhythmic  faradism. 

Medical  Uses.— Various  conditions  other  than  mere 
obesity  are  benefited  by  this  treatment.  The  suitable  dis- 
orders may  be  grouped  undo]1  three  heads:  (1)  Metabolic 
disorders;  (2)  vasomotor  disturbances;  and  (3)  atonies  and 
paralyses. 

Metabolic  Disorders. — In  gout  the  main  purpose  is  to 
promote  elimination.  Reduction  of  superfluous  flesh  may 
be  needed  at  the  same  time,  as  many  gouty  patients  are 
stout  and  lethargic.  If  there  be  high  blood-pressure,  this 
is  also  reduced  by  the  treatment. 

The  suggestion  has  been  made  of  using  the  apparatus  in 


HIGH-FREQUENCY  TREATMENT  405 

cases  of  chronic  nephritis,  but  this  is  open  to  some  objec- 
tions. The  idea  underlying  it  is  that  the  "  chair  "  acts 
as  an  accessory  heart,  and  so  promotes  elimination  here 
also. 

Vasomotor  Disorders. — In  arterio-sclerosis  the  treatment 
assists  the  cardio-vascular  system,  takes  the  strain  off  the 
heart,  and  aids  elimination.  Short  periods  of  treatment 
suffice,  such  as  twenty  minutes  to  half  an  hour  with  a  light 
current. 

In  atonic  conditions  and  paresis  of  limbs,  stomach,  or 
intestine,  good  results  are  achieved.  For  the  latter  the 
stomach  electrodes  are,  of  course,  the  most  important,  and 
good  contact  should  be  insured  by  the  free  use  of  sandbags. 

It  has  been  suggested  that  the  chair  may  be  used  in  the 
place  of  exercise  for  those  who  are  actually  paralyzed  or 
bedridden  and  unable  to  walk. 

In  cardiac  conditions  with  failure  of  compensation  relief 
is  certainly  afforded,  the  faltering  circulation  being  assisted. 
The  rhythmical  contractions  increase  the  vis  a  tergo  and 
lessen  the  tendency  to  anasarca.  Short  sittings  and  light 
weights  only  are  used. 

Obesity. — Cases  of  moderate  stoutness  we  can  only  regard 
as  exaggerations  of  the  normal  structure  of  the  body. 
After  middle  life,  and  sometimes  before,  especially  in  the 
female  sex,  we  see  cases  of  mild  obesity  only  amounting  to 
what  is  called  "full  habit  of  body,"  due  to  overeating  or 
deficient  exercise,  or  both  combined.  Excess  of  fat  also 
makes  walking  more  difficult,  while,  on  the  other  hand, 
much  exercise  may  improve  the  appetite  and  so  tend  in- 
directly to  the  accumulation  of  fat. 

The  Bergonie  system  exercises  the  muscles  and  stimulates 
the  circulaton  without  fatigue  or  strain  on  the  nervous 
system.  A  certain  amount  of  work  is  done  by  the  muscles, 
and  this  is  partly  regulated  by  the  weight  of  sandbags 
employed;  the  heart  is  helped  in  its  work  by  the  promotion 
of  venous  return.  The  effect  of  this  treatment  in  such  cases 
is  very  striking,  and  the  most  gratifying  results  are  often 
obtained.  Apart  from  the  diminution  of  the  body-weight, 
the  stimulation  of  the  lymphatic  and  vascular  system  is 
most  important.  There  is  a  stirring  up  of  latent  masses  of 


406       MANUAL  OF  PHYSIO-THERAPEUTICS 

flesh  with  their  dormant  excretory  products,  as  Dr.  Conn 
well  puts  it. 

In  the  technique  of  treatment  the  most  important  point 
is  to  emphasize  the  obtaining  of  maximum  contractions, 
and  to  use  the  maximum  number  of  sandbags  which  the 
patient  can  do  with.  The  muscular  system  is  thus  exer- 
cised 6cm  gre,  mal  gre,  quite  out  of  proportion  to  the  work 
it  would  do  in  ordinary  pursuits  of  daily  life. 

Sometimes  it  is  quite  feasible  to  leave  the  arms  free  and 
allow  the  patient  to  read,  and  it  is  interesting  to  watch 
how  the  weights  are  lifted  synchronously  with  the  heart- 
beats, the  body  heaving  rhythmically,  while  the  patient 
reads  away  at  a  book  or  newspaper  quite  unconcernedly. 
In  these  cases  the  current  closure  is  lengthened  so  that  the 
moment  of  stimulation  synchronizes  with  the  heart-beat. 

As  regards  the  rate  of  reduction  in  weight,  this  will 
depend  largely  on  the  patient,  the  rate  at  which  the  duration 
of  the  treatment  is  increased,  and  the  intensity  of  the 
treatment,  both,  of  course,  varying  greatly  with  the  personal 
factor.  Rate  of  loss  should  not,  as  a  rule,  exceed  4  pounds 
per  week,  and  will  vary  from  2|  to  3|  pounds  usually. 

It  must  be  clearly  understood  that  diet  cannot  be  dis- 
regarded— indeed,  it  is  an  excellent  principle  for  such 
patients  in  a  measure  to  "feed  on  their  hump."  We  all 
of  us  eat  too  much,  generally  speaking,  and  few  people 
really  understand  how  little  is  necessary  not  only  to  keep 
body  and  soul  together,  but  in  good  health.  The  researches 
of  Chittenden  have  enlightened  us  considerably  in  this 
respect. 

p«  Bergonie  advises  the  free  use  of  salads,  with  free  draughts 
of  tea  (not  too  strong).  Such  a  diet  is  calculated  at  least 
to  fill  the  vacuum  abhorred  by  Nature,  and  supply  a  certain 
amount  of  stimulation.  Alternatively,  a  glass  or  two  of 
light  wine  may  be  taken  with  several  bananas,  which,  for 
all  their  reputation,  are  of  low  nutritive  value.  What  is 
known  as  "a  sinking  sensation "  is  thus  avoided.  The 
diet  generally  advocated  in  cases  of  obesity  is  dealt  with 
more  fully  in  another  section  (p.  447). 

Arterio-sclerosis. — The  objective  in  using  the  treatment 
for  this  serious  affection  is  to  aid  the  cardio- vascular  system, 


HIGH-FREQUENCY  TREATMENT  407 

take  the  strain  off  the  heart,  and  aid  the  elimination  of  the 
causative  factors  of  the  disease,  often  products  of  defective 
metabolism.  Care  should  be  taken  to  use  every  electrode 
provided,  leaving  no  part  of  the  body  out. 

Cardiac  Disease  and  Failing  Compensation. — As  would  .be 
concluded  -from  previous  statements,  the  heart  is  helped 
both  directly  and  indirectly  by  the  treatment,  and  its  value 
should  not  be  lost  sight  of  in  certain  cases  of  morbus  cordis. 
The  rhythmical  contraction  of  the  muscles  assists  the  vis 
a  tergo,  and  the  tissues  are  helped  to  rid  themselves  of  excess 
of  lymph.  Any  tendency  to  oedema  is  thus  minimized. 


SECTION   VI 
DIET  IN  THE  TREATMENT  OF  DISEASE 

CHAPTER  I 
GENERAL  PRINCIPLES  AND  COMPOSITION  OF  FOOD 

DIETETICS  consists  in  the  study  of  the  substances  which 
serve  for  food,  and  the  process  of  nutrition  in  health  and 
disease. 

All  living  creatures  derive  their  nourishment  from  the 
vegetable  kingdom,  either  directly,  or  indirectly  by  living 
upon  animals  which  in  their  turn  subsist  on  vegetables. 
Foods  are  the  substances  which  are  required  for  the  nutri- 
tion and  maintenance  of  the  body  and  for  the  replacement 
of  its  wastes  and  losses. 

In  connection  with  the  nutrition  of  a  healthy  man,  we 
find  that  there  is  great  variety  in  the  nature  and  quality 
of  the  food  substances  used,  as  well  as  in  the  quan- 
tity consumed,  by  different  individuals.  Nevertheless,  the 
three  main  elements  in  all  descriptions  of  human  sustenance 
are  albumin,  carbohydrates,  and  hydrocarbons,  to  which 
may  be  added  water. 

Vegetarians,  such  as  Hindoos,  derive  most  of  their 
sustenance  from  the  vegetable  kingdom,  while  Gauchos, 
Esquimaux,  and  others,  live  almost  entirely  on  animal  food. 
The  happy  and  safe  medium  lies  between  these  two  ex- 
tremes, and  the  highest  dietetic  authorities,  such  as  Voit, 
Pettenkofer,  Chittenden,  and  Pavy,  recommend  a  mixed 
diet  of  animal  and  vegetable  food.  In  this  connection 
Rudolf  Virchow  remarked:  "Although  the  Esquimaux  and 
Kirghiz  show  us  that  life  and  health  can  be  maintained  for 
many  generations  on  an  exclusively  nitrogenous  diet,  and 

408 


GENERAL  PRINCIPLES  OF  FOOD  409 

other  tribes  such  as  the  Hindoos  live  almost  entirely  on 
non-nitrogenous  foods,  yet  history  shows  us  that  the  highest 
attainments  of  the  human  race  have  emanated  from  nations 
who  have  lived  and  do  live  on  mixed  diets.  A  mixed  diet 
taken  partly  from  the  animal  and  partly  from  the  vegetable 
kingdom  is  the  most  suitable  and  digestible  form  of  nourish- 
ment for  mankind." 

We  derive  the  greatest  amount  of  carbohydrates  from 
the  vegetable  kingdom,  while  much  albumin  is  derived  from 
animal  food.  The  proportion  of  vegetable  to  animal 
albumin  in  our  food  should  be  as  3  to  7  (Uffelman). 

The  larger  portion  of  the  food  we  consume  is  employed 
to  generate  the  heat  necessary  for  the  maintenance  of  life, 
only  a  small  portion  going  to  make  up  for  tissue  waste. 
Food  being  thus  intimately  concerned  in  the  production  of 
heat,  it  is  customary  to  speak  of  fcod  in  terms  of  its  heat- 
producing  capacity.  A  heat  unit  is  the  quantity  of  heat 
required  to  raise  the  temperature  of  1  c.c.  of  water  1°  C. 
The  term  commonly  employed  in  calculating  food  energy, 
is  "great  heat  unit"  or  calorie,  by  which  is  meant  that 
quantity  of  heat  energy  which  is  required  to  raise  the 
temperature  of  1  kilogramme  of  water  1°  C.  Each  kind  of 
food  is  ultimately  oxidized  in  the  body  to  its  end-products, 
and  for  the  most  part  exhaled  in  the  form  of  COX,  gas;  the 
more  carbon  atoms  it  contains,  the  more  heat  will  it  generate ; 
thus  1  gramme  of  fat  generates  9-3  calories,  1  gramme  of 
carbohydrates  4-1,  and  1  gramme  of  albumin  4-1  calories. 
The  quantity  of  nourishment  taken  being  ascertained,  it  is 
easy  to  determine  the  energy  value,  or  number  of  calories 
introduced,  by  multiplying  the  different  types  of  food-stuffs 
by  the  above  figures.  The  amount  of  heat  which  it  is 
requisite  for  the  body  to  generate  daily  for  its  maintenance 
has  been  estimated  at  2,500  units  (Koenig). 

Von  Noorden  gives  the  caloric  value  of  food  taken  by 
the  average  working  man  as  40  units  per  kilogramme  of 
body- weight  per  day,  when  working,  and  as  34  units  when 
resting. 

As  stated  above,  a  gramme  of  proteid  in  combustion 
produces  44  calories,  1  gramme  of  fat  9-3  calories,  and 


410        MANUAL  OF  PHYSIO-THERAPEUTICS 

1  gramme  of  carbohydrate  4-1  calories.     In  ounces  this  takes 
the  form — 

1  ounce  protein  produces  .  .  .  .  116  calories. 
1  ounce  of  carbohydrate  produces  116  calories. 
1  ounce  of  fat  produces  . .  .  .  263  calories. 

With  these  data  we  can  calculate  the  calories  from  various 
articles  of  food.  For  instance,  if  we  take  a  sponge  souffle 
or  pudding  containing  in  each  portion  0-305  ounce  protein, 
0-599  ounce  fat,  and  2-46  ounces  carbohydrates,  we  see  the 
multipliers  for  protein  and  starches  are  the  same  at  116, 
and  for  fats  the  multiplier  is  263.  Protein  and  carbo- 
hydrate may  therefore  be  added  together. 

0-305  Take  the  fat  as  0-6,  and  multiply  263 

2461         by  that,  and  we  get  157-8. 

2-766 
117 

321-32 

157-8  Total  calories  equal  479. 

If  we  wish  to  estimate  for  pounds,  we 
479-12  have  to  multiply  by  16. 

Similarly,  with  simple  articles  of  diet  we  can  work  out 
the  calorie  value  very  easily.  For  instance,  a  glass  of 
whole  milk  has  a  calorie  value  of  about  200;  100  grammes 
or  a  small  teacup  72.  Whey  has  a  calorie  value  of  less 
than  one-third  of  this.  An  ounce  of  cream  cheese  has  a 
calorie  value  of  about  100;  an  ounce  of  butter  240;  a  raw 
egg  about  50  calories,  and  so  on. 

By  the  following  tables  it  is  a  simple  matter  to  calculate 
approximately  whether  a  given  quantity  of  food  constitutes 
an  adequate  diet  or  unit : 


GENERAL  PRINCIPLES  OF  FOOD 


411 


COMPOSITION  OF  COMMON  ARTICLES  OF  FOOD 
(AFTER  EINHORN). 

I.  DAIRY  PRODUCTS. 


Albumin, 
per  Cent. 

Fat, 
per  Cent. 

Carbo- 
hydrate, 
per  Cent. 

Calories, 
per  Cent. 

Cow's  milk 

4-0  to  4-3 

3-0  to  3-8 

3-7 

64-0 

Cream 

.    j          3-61 

26-75 

3-52 

276-01 

Butter 

.    i          0-5 

90-0 

0-5 

837-0 

Whey       .  . 
Buttermilk 

.    i          0-5 

.  :        3-0 

0-3                 3-6 
1-3                 3-0 

3-67 

Koumiss  .  . 

3-35 

2-07               3-0 

33-99 

Cream  cheese 

25-0 

30-0                 3-0 

394-0 

Cheese 

.    i        33-0 

9-0                 5-0 

240-0 

Eggs 

.    j        12-5 

12-0                 0-5 

165-0 

II.  MEATS  AND  GAME. 


Albumin, 
per  Cent. 

Fat, 

per  Cent. 

Carbo- 
hydrate, 
per  Cent. 

Calories, 
per  Gent. 

Beef  (fat)            .  .           17-19 

26-38 

_ 

315-81 

Beef  (lean)           .  .           20-78 

1-50 

— 

99-15 

Veal  (fat) 

18-88 

7-41 

0-07 

146-61 

Veal  (lean) 

19-84 

0-82 

— 

86-97 

Mutton  (very  fat) 

14-80 

36-39 

0-05 

399-31 

Mutton  (leaner)  .  . 

17-11 

5-77 

— 

123-81 

Pork  (fat) 

14-54 

37-34 

— 

406-88 

Pork  (lean) 

20-25 

6-81 

— 

146-39 

Ham 

23-97 

36-48 

1-50 

453-69 

Sweetbread 

22-0 

0-4 

— 

93-92 

Pulverized  meat  .  .           64-5 

5-24 

2-28 

322-53 

Poultry    .  .         .  .   :       22-0 

1-0 

— 

100-0 

Spring  chicken  .  .           18-49 

9-34 

1-20 

167-59 

Duck  (wild) 

22-65 

3-11 

2-33 

131-36 

Game 

23-0 

1-0 

— 

103-60 

Hare         .  .          .  .           23-34 

1-13 

0-19 

107-08 

Venison   .  .          .  .           19-77 

1-92 

1-42 

105-44 

412        MANUAL  OF  PHYSIO-THERAPEUTICS 


III.  CEREALS  AND  VEGETABLES. 


Albumin, 
per  Cent. 

Fat, 
per  Cent. 

Carbo- 
hydrate, 
per  Cent. 

•  Calories, 
per  Cent. 

Sago 
Wheat  flour 

0-5 

8-5 

Traces 
1-25 

86-5 
73-0 

356-70 

345-78 

Eye  flour 
Wheaten  bread  .  . 

10-0 
6-0 

2-0 

0-75 

69-0 
52-0 

342-50 
245-0 

Rye  bread 
Roll 

4-5 

6-82 

1-0 

0-77 

46-0 
43-72 

216-0 
213-87 

Zwieback 

9-5 

1-0 

75-0 

356-0 

Cauliflower 

2-0  to  5-0 

0-4 

4-0 

35-0 

Carrots 

1-04 

0-21 

6-74 

33-85 

Asparagus 
Rice 

2-0 
5-5 

0-3 
1-5 

2-5 
76-0 

21-0 
348-10 

Beans 

19-5 

2-0 

52-0 

311-75 

Peas 

.19-5 

2-0 

54-0 

319-95 

Potatoes 

1-5 

_ 

20-0 

88-0 

Oatmeal 

12-5 

5-26   ' 

66-77 

338-80 

Barley  -meal 
Spinach 
Pickles 

8-31 
3-49 
1-02 

0-81 
0-58 
0-09 

75-19 
4-44 
0-95 

323-0 

38-0 

IV.  SOUPS  AND  BEVERAGES. 


'    Garbo- 

Albumin,    ,     Fat,        lwi(iraie 
per  Cent,     per  Cent.     £  Cgn^     per  Cent. 


Milk  soup,  with  wheat 
flour 

5-0 

3-15 

15-0 

112-0 

Meat  broth  (ordinary) 
Meat  juice  (pressed)  .  . 
Beef-lea 

0-4 

6-0  to  7-0 
0-5 

0-6 
0-5 
0-5 

— 

-- 

Leube's  meat  solution 

9-0  to  11-0 

Albumin; 

0-79  to  6-5 

Malt  extract 

peptone 
8-0  to  10-0 

55-0 

258-30 

Barley  soup 
Rice  pap,  with  milk  .  . 
Coffee 

1-5 

8-8 
3-12 

1-0 
3-5 
5-18 

11-0 

28-6 

60-96 
182-61 

Tea        

12-38 

— 

— 

— 

Beer 

0-5 

5-25 

0-3 

— 

Porter  

0-7 

6-0 

0-3 

60-0 

GENERAL  PRINCIPLES  OF  FOOD 
V.  FISH. 


413 


Albumin, 
per  Cent. 

Fat, 
per  Cent. 

Carbo- 
hydrate, 
per  Cent. 

Calories, 
per  Cent. 

Pike 

18-5 

0-5 

0-75 

83-57 

Carp 

20-61 

1-09 

— 

94-64 

Shellfish  .  . 

17-09 

9-34 

— 

156-93 

Salmon     .  . 

15-01 

6-42 

2-85 

132-93 

Oysters     .  . 

4-95 

0-37 

— 

24-0 

Salt  herring 

19-5 

17-0                  0-5 

— 

Caviare     .  . 

.    ,        28-04 

16-26                7-82 

— 

VI.  FRUITS. 


0. 

Free  Acid, 
per  Cent. 

Albumin, 
per  Cent. 

Fat, 

per  Cent. 

Carbo- 
hydrate, 
per  Cent. 

Apples 
Pears 

0-82 
0-20 

0-36 
0-36 

— 

7-22 
3-54 

Plums       .  . 

1-50 

0-40 

— 

4-68 

Peaches    .  . 

0-92 

0-65 

— 

7-17 

Grapes 
Strawberries 

0-79 
0-93 

0-59 
0-54 

0-45 

1-96 
1-01 

Chestnuts 

-  — 

5-48 

1-37 

38-34 

Sugar-cane 
Honey 

.  • 

1-20 

— 

3-40 

5-28 

The  average  male  adult  consumes  in  the  form  of  food 
about  120  grammes  albumin,  90  grammes  fats,  330 
grammes  carbohydrates,  and  2,818  grammes  water  per  day 
(Vierordt). 

Eighty  grammes  of  albumin  per  diem  is  said  to  be  the 
lowest  amount  consistent  with  proper  nutrition.  Food- 
stuffs are  built  up  of  these  four  elements,  and  also  contain 
small  amounts  of  certain  inorganic  salts. 


Animal  Foods. 

These  comprise,  besides  the  flesh  (muscles)  of  the  different 
mammals,  birds,  and  fishes,  several  other  portions  of  their 
bodies,  as,  for  instance,  various  glands,  the  brain,  lungs, 


414        MANUAL  OF  PHYSIO-THERAPEUTICS 

liver,  etc.     Oysters  and  lobsters  also  belong  to  this  group. 
In  most  instances  the  digestibility  of  this  group  of  foods 
corresponds  to  their  richness  in  fat.     The  less  fat  they 
contain,  the  more  digestible  they  are.     Thus  we  have  the 
following  list  of  animal  foods  classified  according  to  their 
digestibility: 

Fat 

per  Cent. 
Calf  s  sweetbread,  veal,  cod-fish,  pike,  oysters     . .          .  .      0-4  to  1 

Beef,  hare,  spring  chicken,  pigeon,  partridge,  carp          .  .       1      ,,   1£ 
Mutton,  pork  . .          .  .          .  .          .  .          .  .          .  .          .  .      5      ,,   7 

Goose,  caviare,  herring,  salmon,  eel  . .          . .          .  .       Over  8 

The  digestibility  of  food  is  also  greatly  dependent  on  its 
quality  and  preparation.  Young  animals  have  soft  and 
tender  meat,  whereas  the  flesh  of  old  ones  is  tough.  The 
different  portions  of  an  animal  vary  in  their  digestibility. 
The  time  that  has  passed  since  the  killing  of  the  animal  is 
also  of  importance.  Fresh  meat  which  is  yet  in  its  rigid 
state  is  tough,  and  therefore  very  indigestible.  In  the 
preparation  of  the  meat  we  must  see  that  it  is  separatee! 
from  all  indigestible  matter  (fascia,  tendons,  cartilage).  By 
pounding  the  meat  the  connective  tissue  surrounding  the 
muscle  fibre  is  torn.  By  chopping,  scraping,  or  pulverizing 
the  meat  its  digestibility  is  increased.  All  other  methods 
of  preparing  meat  only  serve  to  improve  its  taste;  for  raw 
meat  is  more  easily  digested  than  that  which  has  been 
boiled,  broiled,  or  fried.  The  application  of  heat,  however, 
diminishes  the  danger  of  infection,  as  many  micro-organisms 
are  destroyed  by  it. 

Eggs  are  especially  rich  in  albumin  and  fat.  Soft-boiled 
eggs  (three  minutes  in  boiling  water)  are  easiest  to  digest. 
Then  come  raw  eggs  and  scrambled  eggs,  while  hard-boiled 
eggs  and  omelette  are  difficult  of  digestion.  Soft-boiled 
eggs  remain  in  the  stomach  one  and  three-quarter  hours, 
hard-boiled  three  hours. 

Milk  is  intended  as'  the  sole  food  of  young  animals,  and 
as  such  contains  all  the  elements  of  a  typical  diet : 
(1)  Albuminous  substances  in  the  form  of  casein  and  serum 
albumin;  (2)  fats  in  cream;  (3)  carbohydrates  in  the  form 
of  lactose  or  milk  sugar;  (4)  salts,  chiefly  calcium  phosphate; 
and  (5)  water.  Milk  does  not  stay  in  the  stomach  much 


GENERAL  PRINCIPLES  OF  FOOD  415 

longer  than  plain  water,  and  must  therefore  be  considered 
very  digestible. 

Several  articles  of  food  are  obtained  from  milk : 

(a)  Cheese,    which  is  the  casein  precipitated  with  more 
or  less  fat,  according  as  the  cheese  is  made  of  skimmed 
milk  (skim  cheese),  or  fresh  milk  with  its  cream  (Cheddar 
and  Cheshire),   or  of  fresh  milk  plus  cream   (Stilton  and 
double  Gloucester).     The  precipitated  casein  is  allowed  to 
ripen,  by  which  process  some  of  the  albumin  is  split  up, 
with  formation  of  fat. 

(b)  Cream  consists  of  the  fatty  globules  encased  in  casein, 
and  which,  being   of  lowest   specific  gravity,   rise  to  the 
surface. 

(c)  Butter   is   the    fatty    matter    deprived    of    its    casein 
envelope  by  the  process  of  churning. 

(d)  Buttermilk  is  the  fluid  obtained  from  cream  after  butter 
has  been  formed:     It  is  therefore  very  rich  in  nitrogen. 

(e)  Whey  is  the  fluid  which  remains  after  the  precipitation 
of  casein.     It  contains  sugar,  salt,  and  a  small  quantity  of 
albumin. 

Vegetable  Foods. 

All  these  contain  more  or  less  carbohydrates,  and  the 
principal  amount  of  carbohydrates  of  our  diet  is  obtained 
from  them. 

1.  Foods    Rich   in    Proteids. — Leguminous   foods    (peas, 
beans,  lentils,  etc.)  contain  a  nitrogenous  substance  called 
legumin  (which  is  allied  to  albumin)   in  the  proportion  of 
25  per  cent.     They  form  a  chief  source  of  the  nitrogen  of 
the  food  of  vegetarians. 

2.  Foods  Rich  in  Carbohydrates. — Cereals.     Bread   made 
from  the  ground  grain  of  various   so-called  cereals,   such 
as  wheat,  rye,  maize,  barley,  rice,  oats,  etc.,  is  the  most 
direct  form  in  which  carbohydrate  is  supplied  in  an  ordinary 
diet.     Besides  starch,  bread  contains  gluten  (a  nitrogenous 
body)  and  a  small  amount  of  fat.     White  bread  is  easier  to 
digest    than   brown.     Various   articles    of   food   are    made 
from  flour — viz.,  spaghetti,  macaroni,  and  biscuits. 

The  following  table  gives  the  approximate  percentage 
composition  of  some  of  the  principal  food-stuffs : 


416         MANUAL  OF  PHYSIO-THERAPEUTICS 
PERCENTAGE  COMPOSITION  OF  FOODS. 


Water. 

Proteids.  Starch. 

\ 

Sugar. 

Fat. 

Salts. 

Bread             .  .          37              8 

47 

3 

1 

2 

Wheat  flour  .  . 

15            11 

66 

4-2 

2 

1-7 

Oatmeal 

15            12-6 

58 

5-4 

5-6 

3 

Rice 

13             6 

79 

0-4 

0-7 

<;-5 

Peas  (split)    .  . 

15 

23 

55 

2 

2 

•      2 

Potatoes 

75 

2 

18 

3 

0-2 

0-7 

Milk 

86 

4 

—  . 

5 

.3-8 

0-8 

Cheese 

37 

33 

— 

— 

9 

5 

Lean  beef 

72 

19 

— 

—  . 

3 

5 

Fat  beef 

51 

24 

— 

— 

29 

4 

Mutton 

72 

18 

—     . 

5 

5     . 

Veal 

63 

16 

— 

16 

4 

White  fish     .  . 

78 

18 

— 

3 

1 

Salmon 

77            16 

— 

5-5 

1-5 

Eggs     ..         ..          74            14 

12 

1-5 

Butter.  .         .  .          15 

•  — 

|     83 

2 

Vitamins. 

These  substances  have  attracted  a  good  deal  of  attention 
during  the  past  few  years,  but  as  yet  our  knowledge  of  them 
is  limited  and  somewhat  vague.  Whether  they  are  of  the 
nature  of  ferments  or  what  is  exactly  their  chemical  nature 
we  have  no  exact  knowledge,  but  they  are  now  looked 
upon  as  essential  ingredients  in  the  food  of  the  human 
species.  Scurvy  was  formerly  attributed  to  a  lack  of 
potash  salts  in  the  food,  but  is  much  more  probably  due 
to  lack  of  vitamin.  Infantile  scurvy  is  produced  by 
using  boiled  or  pasteurized  milk  without  the  accompani- 
ment of  fruit  juices  in  some  form,  and  we  may  safely  con- 
clude that  heating  of  milk  above  a  certain  temperature 
destroys  the  essential  vitamin. 

There  are  three  varieties  which  have  been  so  far  in- 
vestigated : 

Fat-soluble  Vitamin  A,  which  has  been  found  essential 
for  the  growth  of  young  animals.  This  has  not  yet  been 
isolated,  but  its  presence  in  certain  fat  foods  has  been 
clearly  demonstrated.  If  it  is  absent  from  the  food  of 
young  mammals  the  growth  is  checked,  and  there  is  but 


GENERAL  PRINCIPLES  OF  FOOD  417 

a  feeble  resistance  to  bacterial  invasion.  This  substance 
is  absent  from  vegetable  fats,  and  even  some  kinds  of 
animal  fats,  and  when  present  is  easily  destroyed  by  cooking. 

Water-soluble  Vitamin  B,  sometimes  called  antineuritic 
vitamin,  has  not  yet  been  isolated  either,  but  biological 
experiments  prove  that  it  is  essential  in  the  diet  of  animals. 
This  was  first  discovered  on  Christmas  Island  (in  the 
Pacific)  during  an  outbreak  of  beri-beri,  when  it  was  shown 
that  the  epidemic  was  traceable  to  the  use  of  polished 
rice,  the  polishing  process  removing  the  necessary  vitamin. 
Animals  from  which  this  substance  is  withheld  degenerate 
rapidly,  owing  to  atrophy  of  their  secretory  organs.  But 
recovery  quickly  takes  place  on  food  containing  the  vitamin 
being  freely  administered. 

Water-soluble  Vitamin  C  is  sometimes  known  as  anti- 
scorbutic vitamin.  It  is  found  in  the  juices  of  fruit  and 
most  uncooked  vegetables.  It  is  extremely  unstable,  and 
is  usually  destroyed  by  any  of  the  ordinary  cooking  or 
preserving  methods. 

Recent  research  demonstrates  the  value  of  a  small  quan- 
tity of  orange  juice  or  grape  juice  added  to  the  food  of 
bottle-fed  babies  daily. 

Probably  we  are  only  on  the  threshold  of  much  more 
important  discoveries  in  regard  to  these  interesting  bodies. 

The  Influence  of  Cooking  on  the  Digestibility  of 
Certain  Foods. 

Raw  flesh  has  only  one  inconvenience — it  sticks  to  the 
teeth — otherwise  it  is  not  at  all  unpleasant  to  taste. 
Seasoned  with  a  little  salt,  it  is  easily  digested,  and  must 
be  at  least  as  nourishing  as  in  any  other  form.  Man  is  a 
cooking  animal,  but  broadly  it  may  be  stated  that  most 
forms  of  cooking  actually  lessen  the  digestibility  of  animal 
foods,  rendering  them  in  some  cases  tough  and  leathery, 
whilst  they  increase  that  of  vegetable  foods.  It  is  a  clinical 
fact  that  manj'  patients  can  take  raw  or  greatly  under- 
done meats  more  easily  than  other  forms  of  nourishment. 
This  lessening  of  the  digestibility  of  animal  foods  by  cooking, 
regarded  clinically,  is  in  a  measure  made  up  for  by  acl- 

27 


418        MANUAL  OF  PHYSIO-THERAPEUTICS 

vantages  in  their  improved  appearance  and  greater  attrac- 
tiveness, and  by  the  new  flavours  developed  in  them  serving 
to  stimulate  the  secretion  of  gastric  juice.  They  are  also 
wholly  or  partly  sterilized.  The  general  effect  of  cooking 
on  the  structure  of  meat  is  to  loosen  its  fibres  by  converting 
into  gelatine  the  connective  tissue  which  holds  them  together, 
and  to  remove  fat;  the  chief  effect  on  the  chemical  com- 
position of  meat  is  to  diminish  the  amount  of  its  water. 
That  meat  is  rendered  less  digestible  in  proportion  to  the 
degree  of  cooking  it  undergoes  is  shown  by  the  fact  that 
3-|-  ounces  of  beef,  taken  raw,  disappear  completely  from 
the  stomach  in  two  hours;  if  half-boiled,  in  two  and  a  half 
hours;  if  wholly  boiled,  in  three  hours;  if  half-roasted,  in 
three  hours;  and  if  wholly  roasted,  in  four  hours. 

The  effect  of  heat  on  the  proteids  of  food  is  to  coagulate 
them,  which  is  effected  at  a  temperature  of  about  77°  C. 
If  the  temperature  reached  in  cooking  be  beyond  this, 
the  value  of  the  food  is  lessened  by  the  hardening  and 
shrinking  of  the  proteid  materials.  The  value  of  this  fact, 
in  its  practical  application  to  cooking,  has  long  been  re- 
cognized, though,  unfortunately,  it  is  commonly  disregarded 
in  practice.  In  boiling  meat  it  should  be  plunged,  for  a  few 
minutes  only,  in  boiling  water,  sufficient  just  to  cover  it, 
when  the  superficial  proteids  are  coagulated,  the  joint  is 
"  sealed,"  and  its  salts  and  extractives  retained.  The 
cooking  should  then  be  continued  at  a  much  lower  tem- 
perature. With  the  exception  of  frying,  it  may  be  said 
generally  that  slow  cooking  is  good  cooking. 

In  roasting,  the  joint  should  be  placed  immediately 
close  to  the  fire  for  a  few  minutes  until  it  is  "  sealed,"  and 
then  moved  back,  the  drying  of  the  continued  roasting 
being  prevented  by  persistent  basting.  In  frying,  the 
meat  should  be  plunged  suddenly  into  a  deep  pan  of  nearly 
boiling  fat  (or  pure  olive  oil).  The  intense  heat  produces 
instantaneous  coagulation  of  the  proteids  on  the  surface. 
So  soon  as  the  "  sputtering  "  has  ceased — in  two  or  three 
minutes — the  cooking  is  completed. 

In  the  cooking  of  vegetables  the  moist  heat  swells  up 
the  starch  grains  and  ruptures  their  envelopes,  so  that  the 
starch  grains  form  a  paste  or  starch  jelly.  Unfortunately, 


GENERAL  PRINCIPLES  OF  FOOD  419 

though  cooking  increases  the  digestibility  of  green  vegetables, 
it  still  further  reduces  their  already  low  nutritive  value. 
Their  chief  value  lies  in  their  bulk  and  in  their  mineral 
salts. 

The  fats  are  less  affected  by  heat  than  the  proteids  and 
carbohydrates.  By  high  temperature  some  of  the  fat  may 
undergo  partial  decomposition,  by  which  free  fatty  acid 
is  liberated.  It  is  suggested  that  the  greater  digestibility 
of  cold  fat  over  hot  is  accounted  for  by  the  fatty  acid 
reuniting  with  glycerine  to  form  neutral  fat  on  cooling. 


Tea  and  Coffee. 

These  resemble  one  another  in  that  they  both  owe  their 
dietetic  value  and  stimulating  properties  to  the  presence  of 
alkaloids  identical  in  character — viz.,  theine  and  caffeine. 
Tea  is  used  in  this  country  to  such  a  vastly  greater  extent 
than  coffee  that  a  few  words  may  be  devoted  to  the  con- 
sideration of  it  from  the  dietetic  point  of  view. 

Formerly  most  of  our  tea  came  from  the  Celestial  Empire, 
but  in  the  latter  part  of  the  last  century  Indian  and  Ceylon 
teas  became  so  popular  as  largely  to  displace  China  tea  in 
the  public  favour.  During  the  past  few  years  a  change  has 
occurred,  and  China  tea  is  steadily  gaining  favour  again. 
On  physiological  grounds  this  is  a  desideratum.  Both 
Indian  and  Ceylon  teas  yield  much  more  of  the  deleterious 
tannin  in  their  infusion  than  good  China  tea.  Further, 
the  longer  Indian  tea  is  infused  the  more  tannin  is  yielded. 
When  infused  for  ten  minutes  Indian  tea  yields  nearly 
twice  as  much  tannin  as  China  tea,  and  thus  tea  from 
India  and  Ceylon  is  much  more  prone  to  cause  gastric 
disturbance  and  discomfort  in  sensitive  persons  than  China 
tea. 

The  greatest  ignorance  prevails  on  this  subject,  and 
there  are  a  very  large  number  of  people  who  have 
given  up  tea  altogether,  and  who  try  to  satisfy  their 
wants  with  cocoa  or  milk  and  water,  who,  did  they  know 
of  its  value,  would  be  perfectly  able  to  take  and  enjoy 
good  China  tea. 


420        MANUAL  OF  PHYSIC-THERAPEUTICS 

Those  who  have  become  accustomed  to  the  somewhat 
harsh  and  stronger  flavour  of  Indian  tea  are  inclined  to 
complain  that  China  tea  is  flavourless.  This  is  far  from 
the  case.  Good  class  China  tea  has  a  peculiarly  fine  flavour 
all  its  own,  but  the  cheaper  sorts  do  not  make  very  pleasant 
beverages.  The  late  Sir  Andrew  Clark  and  Dr.  Samuel 
Fenwick  were  both  strenuous  advocates  of  good  black 
China  tea. 

There  is  no  doubt  whatever  that  in  this  country  an 
immense  amount  of  ill-health  and  suffering  is  caused  by 
the  abuse  of  tea,  which,  so  far  as  abstainers  from  alcohol 
are  concerned,  may  be  described  as  the  national  beverage. 
The  harm  done  is,  indeed,  only  second  to  that  caused  by 
alcohol.  Abuse  is  both  qualitative  and  quantitative.  Some 
people  drink  tea  to  excess  habitually,  and  when  they  begin 
to  suffer  from  irritable  nerves,  sleeplessness,  palpitation,  and 
muscular  tremors,  they  wonder  "Why?"  Among  the 
working  classes  the  cheaper  kinds  of  tea,  consisting  largely 
of  the  mid-rib  of  the  leaf,  are  used,  and  these  contain  a 
proportionately  greater  amount  of  taimin. 

It  is  a  remarkable  fact  that  the  British  hostess  among 
the  upper  middle  classes  will  guilelessly  offer  the  late  caller 
who  confidingly  trusts  in  her  hospitality  a  cup  of  a  beverage 
which  would  temporarily  inhibit  the  peptic  processes  of  an 
ostrich,  and  which  is  wholly  devoid  of  stimulating  and 
refreshing  properties. 

The  meal  so  popular  among  certain  classes  under  the  name 
of  "  high  tea  "  is  neither  dinner  nor  breakfast,  but  is  a 
physiological  atrocity  which  should  be  strenuously  avoided. 
The  digestion  of  freshly  cooked  meats  is  greatly  delayed  by 
the  presence  of  a  strong  infusion  of  tea.  For  persons  with 
indifferent  assimilative  powers  tea  taken  three  hours  after 
a  meal  is  least  likely  to  interfere  with  digestion;  it  is  at 
once  refreshing  and  an  aid  to  that  process,  as  it  helps  to 
empty  the  stomach.  The  five  o'clock  cup  of  tea  which  has 
of  late  years  become  so  popular  is  therefore  physiologically 
sound. 


GENERAL  PRINCIPLES  OF  FOOD  421 


Alcoholic  Beverages. 

It  would  be  hazardous  in  the  extreme — even  did  space 
permit — to  deal  at  any  length  with  the  vexed  subject  of 
alcohol,  so  much  difference  of  opinion  existing  on  the 
subject,  not  only  among  the  laity,  but  the  profession.  It 
may  be  safely  said  that  a  very  large  proportion  of  the 
medical  profession  are  total  abstainers.  This  is  largely 
due,  doubtless,  to  the  amount  of  suffering  and  wretchedness 
which  they  see  in  the  pursuit  of  their  profession  owing  to 
the  abuse  of  alcohol  by  some  of  their  patients. 

The  use  of  alcohol  has  the  sanction  of  all  the  ages  from 
the  time  of  Noah  to  the  present  day.  No  reasonable 
person  can  deny  that  it  was  given  us  for  our  use.  Whether 
we  shall  use  it  or  not,  and  whether,  if  we  use  it,  we  are 
likely  to  abuse  it,  each  individual  must  decide  for  himself. 
In  spite  of  all  that  has  been  said  by  the  ultra-total-abstinence 
fraternity,  there  can  be  no  question  that,  dietetically  con- 
sidered, we  have  in  alcohol  a  valuable  stimulant. 

Burney  Yeo  well  says  that  it  is  at  once  a  useful  food,  an 
agreeable  stimulant,  and  a  narcotic  poison,  according  to 
the  dose  in  which  it  is  taken  and  the  tissue  reactions  of 
the  individual  to  whom  it  may  be  administered.  Parkes' 
dictum  that  from  1  to  1|  ounces  of  absolute  alcohol  in  the 
twenty-four  hours  is  the  maximum  amount  which  a  healthy 
man  should  take,  "  either  in  the  form  of  wine,  beer,  or 
spirits,"  is  regarded  by  the  large  majority  of  physicians  as 
eminently  sound. 

In  small  quantities,  taken  with  food,  alcohol  in  most 
people  improves  the  appetite  and  increases  the  enjoyment 
of  food,  and  secondarily  improves  digestion.  Many  people 
take  their  food  with  greater  relish  and  pleasure  when  accom- 
panied by  a  glass  of  wine,  and  pleasure  aids  digestion.  The 
sweeping  statements  of  temperance  fanatics  as  to  the 
poisonous  properties  of  alcohol  are  to  be  accepted  with  the 
greatest  reserve.  Gluttony  is  scarcely  less  objectionable 
than  alcoholic  intemperance.  Unquestionably  thousands 


422        MANUAL  OF  PHYSIO-THERAPEUTICS 

of  people  die  annually  as  a  direct  or  indirect  result  of  the 
abuse  of  alcohol,  but  it  is  open  to  honest  doubt  whether  as 
many  individuals  do  not  die  prematurely  from  overeating 
as  from  overdrinking. 

The   percentage   of   alcohol   contained   in  the   usual  in- 
toxicating beverages  is  set  out  in  the  following  table : 


Rum 

60  to  75 

Burgundy 

8  to  14 

Whisky 

50 

60 

Claret     .  . 

8  , 

12 

Brandy  (British) 

50 

60 

Moselle  .  . 

8  , 

12 

Brandy  (French) 

50 

55 

Rhine  wines 

7 

16 

Gin 

48 

60 

Chablis  .  . 

7 

10 

Port      .  . 

15 

18 

Champagne 

6 

13 

Marsala 

15 

21 

Bitter  ale 

6 

9 

Sherry  .  . 

14 

18 

Porter    .  . 

4 

7 

Madeira 

14 

17 

Cider 

2 

9 

Sauterne 

11 

18 

Beer 

2 

4 

Hungarian  wines 

9 

15 

Ginger  beer  (brewed)  . 

1 

3 

During  the  war  the  value  of  a  tot  of  rum  in  the  trenches 
was  proved  beyond  doubt,  and  testified  to  strongly  by 
medical  and  executive  officers. 

At  the  present  moment  America  has  gone  dry — whether 
to  remain  so  or  not  is  a  matter  of  conjecture — and  Mr. 
"  Pussyfoot  "  Johnson  has  been  engaged  in  a  prohibition 
campaign  in  this  country.  We  must  confess  we  resent 
such  efforts,  and  they  are  hardly  likely  to  find  general 
acceptance  with  the  nation. 


Relative  Digestibility  of  Foods. 

Foods  are  described  as  easily  digestible  and  indigestible, 
or  difficult  of  digestion.  These  terms  require  some  quali- 
fication. It  is  not  sufficient  merely  to  consider  the  time 
taken  to  complete  gastric  digestion  of  any  food;  its  digesti- 
bility in  the  intestine  must  be  taken  into  account,  and  the 
index  of  intestinal  utilization  is  the  amount  of  residue 
excreted  by  the  bowels. 

The  approximate  time  taken  for  the  gastric  digestion  of 
common  articles  of  diet  is  shown  in  the  following  table  : 


GENERAL  PRINCIPLES  OF  FOOD 


423 


TIME-TABLE  FOR  GASTRIC  DIGESTION. 


Articles  of  Diet. 


Time  required  for 
Digestion. 


Beef,  boiled     .  .          .  .  .  .  .  .  .  .  .  .  3  hours. 

,,    roasted   .  .          .  .  .  .  . .  .  .  .  .  3  to  4  hours. 

,,    smoked  .  .          .  .  .  .  .  .  .  .  .  .  4  ,,   5      ,, 

Fish,  boiled     .  .          .  .  .  .  . .  .  .  .  .  1J  to  2J  hours. 

Oysters  (raw)              .  .  . .  .  .  .  .  .  .  2  hours. 

Lamb    .  .          .  .          .  .  .  .  .  .  .  .  .  .  2J    ,, 

Mutton,  boiled            .  .  . .  .  .  . .  .  .  3      ,, 

,,        roasted          .  .  .  .  .  .  .  .  .  .  3  to  3J  hours. 

Milk 2  hours. 

Sweetbread     .  .          .  .  .  .  .  .  .  .  .  .  2       ,, 

Ham,  boiled    .  .          .  .  .  .  .  .  .  .  .  .  2  to  3  hours. 

Pork,  roasted              .  .  .  .  .  .  .  .  .  .  5  hours. 

Poultry,  boiled  or  roasted  .  .  .  .  .  .  .  .  2J  to  4  hours. 

Goose,  roasted            .  .  .  .  .  .  .  .  .  .  4    ,,   5      ,, 

Tripe    .  .           .  .           .  .  .  .  .  .  .  .  .  .  1  hour. 

Veal  (as  prepared  in  the  British  Isles)  .  .  .  .  4J  hours. 

Eggs,  raw        .  .          .  .  . .  . .  .  .  . .  2         ,, 

,,     fried  or  boiled  hard  .  .  .  .  .  .  .  .  3   to  3f  hours. 

Cheese              .  .          .  .  .  .  .  .  .  .  .  .  3         4 

Apples              .  .          .  .  .  .  .  .  .  .  .  .  3         4 

Cabbage           . .          .  .  .  .  .  .  .  .  .  .  3J       4 

Carrots  3          3J 

Potatoes          .  .          .  .  .  .  .  .  . .  .  .  2J       3| 

Turnips            .  .           .  .  .  .  .  .  .  .  .  .  3|       4 

Rice       ^  /'I         2 

Sago        Uf  completely  cooked  .  .  .  .  1         2 

Tapioca  J  (l         2 

"Wheaten  bread  3         4 


Ail  ordinary  dinner  is  completely  digested,  leaving  the 
stomach  empty,  in  five  to  seven  hours  in  the  normal  indi- 
vidual. 


CHAPTER  II 
DIET  IN  HEALTH  AND  IN  THE  INDIVIDUAL 

THE  diet  which  we  accustom  ourselves  to  when  in  health 
should  not  always  consist  of  the  most  easily  digested  sub- 
stances; by  so  doing  we  may  weaken  our  digestive  system. 
While  not  going  out  of  our  way  to  select  articles  notori- 
ously difficult  of  digestion,  it  is  certainly  not  necessary  or 
desirable  that  they  should  be  avoided  if  the  palate  suggests 
them.  A  healthy  diet  is  made  up  of  a  mixture  in  fair 
proportion  of  substances  easy  and  difficult  to  digest,  the 
former  preponderating.  Those  foods  which  are  usually 
found  "  digestible  "  and  "  indigestible  "  are  indicated  below. 

Digestible. — Soups  (clear);  fish  (except  mackerel,  salmon, 
crab,  lobster,  and  eel);  chicken,  fowl,  pigeon,  game  (not 
"high"),  lamb,  mutton;  toasted  or  well-boiled  bacon; 
tripe,  sweetbread,  cow-heel,  calf's  head;  dry  toast,  plain 
rusks,  stale  bread;  other  farinaceous  foods  when  in  modera- 
tion, well-cooked  potatoes,  spinach,  green  vegetables 
generally  in  only  small  quantity;  celery,  French  beans; 
fruit  (without  pips,  core,  or  skin)  in  small  quantity;  milk, 
plain,  or  diluted  with  Vichy,  soda,  or  seltzer  water;  tea 
(freshly  made  and  not  strong,  and  preferably  China),  coffee 
(not  black),  thin  cocoa. 

Difficult  of  Digestion. — New  bread,  wholemeal  bread 
(usually),  muffins,  crumpets,  buttered  toast,  pastry  and 
sweets  generally;  hard,  long-fibred  meats,  veal,  pork,  and 
beef;  sauces,  curries;  all  fried  or  recooked  meats;  fat 
or  rich  food  such  as  duck,  goose,  and  eels;  green  vegetables 
generally,  save  in  small  quantities  for  those  whom  they  are 
known  to  suit;  soups  and  broths,  except  in  small  quantity; 
foods  generally  which  leave  a  large  residue  or  which  are  in 
their  nature  irritating,  such  as  seed?,  kernels,  rinds,  skins, 

424 


DIET  IN  HEALTH  AND  IN  THE  INDIVIDUAL     425 

and  stalks;  acid  or  unripe  fruits;  sour  wines;  tea  with 
meat,  or  otherwise,  unless  of  moderate  strength  and  freshly 
infused. 

In  regard  to  individuality  of  stomachs,  a  well-known 
physician  speaks  as  follows:  "  If  asked  by  a  patient,  '  What 
shall  I  eat,  doctor  ?'  say,  'Eat  what  you  like!'  If  he 
says,  'How  much?'  reply,  'As  much  as  your  appetite 
demands!'  If  he  asks,  'When1?'  say,  'When  you  are 
hungry  !'  '  Unfortunately,  though  this  may  be  safe  where 
the  normal  instinct  exists,  it  is  very  often  lost  in  dyspepsia 
and  stomach  disease,  and  such  patients  either  eat  too  much 
and  too  often,  or  more  frequently  almost  starve  themselves. 

No  absolutely  definite  rules  can  be  laid  down  as  to  the 
hours  for  eating.  These  will  be  influenced  by  so  many 
different  factors,  such  as  the  wishes  of  the  individual,  the 
size  of  the  meals,  and  the  exigencies  of  business.  The  more 
irregularity  which  the  individual  can  tolerate  without 
suffering  or  discomfort,  the  higher  his  standard  of  health. 

So  far  as  the  substances  included  in  the  diet  of  any 
individual  are  concerned,  in  spite  of  the  valuable  work  of 
Chittenden  and  other  prominent  dietitians  and  physio- 
logists at  the  present  day,  the  fact  remains  that  the  practical 
physician  has  no  little  difficulty  in  formulating  any  defini- 
tion of  the  normal  diet  for  a  healthy  man  or  woman.  We 
cannot  help  realizing  that  among  a  number  of  individuals 
in  perfect  health,  of  approximately  the  same  age  and  body- 
weight,  and  performing  a  similar  amount  of  physical  labour, 
the  food  necessary  to  sustain  them  and  keep  up  physical 
vigour  varies  greatly  in  quantity  and  character.  While 
the  general  principle  holds  good  that  given  quantities  of 
flesh  food,  bread-stuffs,  milk,  butter,  sugar,  and  condiments 
—representing  the  essential  proportions  of  proteids,  carbo- 
hydrates, and  hydrocarbons,  etc..  and  their  caloric  value — 
are  necessary  for  the  average  individual,  yet  the  quantity 
of  these  consumed  may  be  in  inverse  proportion  to  the 
size  and  stature  of  the  individual;  for  we  often  find  very 
small  and  very  lean  people  consume  much  larger  amounts  of 
food  than  those  of  much  ampler  proportions. 

Moreover,  we  find  many  men  regard  a  beef -steak  as  the 
staff  of  life  and  foundation  of  physical  energy,  and  look 


426        MANUAL  OF  PHYSIO-THERAPEUTICS 

with  pitying  contempt  on  the  person  who  relies  mainly 
for  his  sustenance  on  protein-containing  vegetables  and 
starchy  dishes.  Sir  William  Roberts  used  to  say,  "  Our 
stomachs  [meaning  our  digestive  capacity  and  palates] 
are  like  our  faces,"  and  this  very  suggestive  remark  is 
only  another  way  of  saying  one  man's  meat  is  another 
man's  poison. 

Physiological  principles  and  facts  only  hold  good  to  a 
certain  degree,  and  it  must  be  admitted  that  the  dietaries 
of  institutions  such  as  prisons  poor-houses  and  schools, 
based  on  stereotyped  proportions  of  food-substances,  are 
not  wholly  satisfactory  in  results  nor  satisfying  to  all  the 
individuals  concerned.  In  prisons,  while  some  convicts 
get  on  fairly  well  as  regards  diet,  a  proportion  are  invariably 
ravenously  hungry.  Again,  in  schools  some  children  are 
much  happier  and  healthier  when  the  amount  of  protein 
food  is  diminished  and  fats  and  starches  increased,  and 
vice  versa. 

It  is  useless  ever  to  prescribe  a  dietary  without  taking 
into  account  the  factor  of  personal  idiosyncrasy,  and 
Trousseau  recognized  this  fact  many  years  ago. 

One  of  the  most  common  metabolic  idiosyncrasies  is 
intolerance  of  purin-containing  food-stuff,  especially  such 
articles  as  butcher's  meat  and  strong  tea  and  coffee.* 
While  the  majority  of  mankind  are  quite  capable  of  con- 
suming these  articles  with  enjoyment,  and,  after  abstracting 
a  considerable  amount  of  nourishment  from  them,  eliminat- 
ing the  by-products  of  digestion,  such  as  xanthin,  hypo- 
xanthin,  adenine,  guanine,  and  uric  acid,  without  taking 
any  hurt,  not  a  few  individuals  suffer  in  no  light  degree  from 
consuming  them.  The  writer  remembers  a  valued  domestic 
servant  once  in  his  service  who  lived  entirely  on  porridge, 
milk,  cheese,  bread  and  jam,  butter,  and  weak  tea  or  milk 
and  water,  and  maintained  a  good  standard  of  health,  and 
in  whom  the  slightest  departure  from  this  restricted  dietary, 
such  as  the  consumption  of  a  small  portion  of  fresh  fish, 
resulted  in  a  migraine  attack  and  much  discomfort  and 
mental  depression. 

*  Free  and  bound  purins  in  common  articles  of  diet,  according 
to  Dr.  Walker  Hall. 


DIET  IN  HEALTH  AND  IN  THE  INDIVIDUAL      4,21 


Fisjt  •'  Purins. 

Cod  ..          ..          ..          ..     grains  per  pound    4-07 

Salmon         .  .          .  .          .  .  ,,  ,,  8-15 

Meat  : 

Mutton         „  ,,  6-75 

Beef  ,,  „  7-96-14-45 

Chicken        „  „  9-06 

Liver  ,,  „  19-26 

Sweetbread  .  .          .  .  ,,  ,,  70-43 

Eggs  and  Cheese,  almost  ,,  ,,  0 

Vegetables  : 

White  bread,  rice  .  .  .  .  ,,  ,,  0 

Cabbage,  cauliflower,  lettuce  ,,  ,,  0 

Potatoes      .  .  .  .  .  ,,  ,,  0-14 

Asparagus   .  .  .  .  .  ,,  ,,  1-5 

Peas  .  .  .  .  .  ,,  ,,  3-54 

Oatmeal       .  .  .  .  .  ,,  ,,  3-46 

Beans  .  .  .  .  .  ,,  ,,  4-16 

Beverages  : 

Wines  .  .          .  .          .  .     grains  per  pint  0-0 

Milk  ,,  ,,  0-0014 

Beer  ,,  ,,  1-09-1-27 

China  tea  (methyl  purins)  grains  per  tea-cup  0-075 

Ceylon  tea  ,,  ,,  ,,  ,,  1-21 

Coffee  ,,  „  „  ,,  1-7 

Such  cases  are,  indeed,  very  common,  and  though  one 
may  hardly  be  disposed  to  admit  the  soundness  of  all  the 
pronouncements  of  Alexander  Haig,  the  well-known  writer 
on  the  subject  of  uric  acid,  still  there  is,  unquestionably, 
a  large  proportion  of  truth  in  them,  and  many  of  our  aches 
and  pains  and  attacks  of  "the  blues"  must  be  due  to  a 
quantitatively  faulty  dietary,  and  the  daily  endeavour  of 
a  certain  type  of  metabolic  activity  to  deal  with  nutritive 
material  which  it  is  quite  incapable  of  handling.  It  is 
perhaps  too  much  to  say  that  every  individual  suffering  in 
this  manner  is  unhealthy  or  physically  abnormal.  Few 
people  are  absolutely  healthy  if  the  highest  standard  and 
conception  of  health  be  taken.  The  pathologists  who  take 
a  somewhat  morbid  view  of  this  question  often  declare  no 
one  is  iri  a  condition  of  perfect  health. 

The  maintenance  of  a  condition  of  health  and  physical 
comfort,  so  far  as  the  results  of  feeding  are  concerned,  will 
depend  in  very  many  instances  on  a  careful  study  of  the 
individual  as  regards  his  digestive  and  metabolic  capacities 


428       MANUAL  OF  PHYSIO-THERAPEUTICS 

or   powers.     There   are   many   thousands   of  people    in   a 
condition  of  misery  and  physical  incapacity  at  the  present 
time  from  the  constant  occurrence  of  headaches  and  bilious- 
ness  due   to   auto-intoxication,    who   may  be   entirely  re- 
habilitated and  literally  set  on  their  feet  by  the  careful 
removal  of  purin-containing  bodies  from  their  daily  dietary. 
On  the  other  hand,  there  are  a  very  large  number  of 
people    whose    nutritional    equilibrium    and    mental    and 
physical  activity  can  only  be  maintained  by  a  diet  contain- 
ing a  large  proportion  of  animal  food,   who  fall  into  ill- 
health  on  a  starchy  diet,  and  to  whom  milk  puddings  are 
as  great  a  poison  as  black  coffee  and  beef-steaks  are  to  the 
man   intolerant    of   purins.     Such   individuals   often   have 
a  higher  percentage  of  free  HC1  in  the  gastric  juices  than 
the  normal  physiological  man;  and,  further,  occupation  and 
habits   have   much   to   do   with   the   matter.     Though  the 
physiologist   may   dogmatically  lay   down  to   a   grain  the 
exact    amount    and    proportion    of    food    for    the    normal 
individual — according  to  whether   his  occupation  is  light, 
medium,  or  heavy  labour — we  are  still  compelled  to  recognize 
the    fact    that    healthy    people    vary    immensely    in    their 
metabolic  activity.     Whatever  may  be  the  caloric  value  of 
the  food  they  consume,  one  must  remember  that  it  is  trans- 
formed   in   very    varying    degrees   and   ways   into    kinetic 
energy  by  the  chemical  changes  which  it  undergoes  after 
absorption.      There    is    much    more    rapid    and    complete 
combustion  with  some  individuals  than  with  others.     We 
require    to   recognize    clearly    that    different    qualities   and 
perhaps  quantities  of  fuel  are  necessary  to  keep  the  various 
types  and  temperaments  of  the  human  machine  in  good 
working  order;  and  the  person  whose  metabolism  requires 
more  of  one  element   than  of  another  in  his  daily  dietary 
can  only  be  properly  regarded  as  abnormal  and  diseased 
when   his   chemical  processes   are  rendered  faulty   by   his 
endeavouring  to  exist  on  stereotyped  and  conventional  lines 
to  which  he  is  physiologically  ill  adapted. 

Milner  Fothergill,  for  instance,  emphasized  the  value  of 
sugar  in  the  form  of  "  toffee  "  for  children,  and  the  love  for 
sweet  things  which  young  people  almost  invariably  evince 
must  be  regarded  as  essentially  normal  and  physiological. 
Their  desire  for  heat-producing  sugar,  it  is  important  to 


DIET  IN  HEALTH  AND  IN  THE  INDIVIDUAL      429 

note,  most  frequently  coexists  with  an  equally  strong  dislike 
of  fat  foods. 

Parents,  and  those  concerned  in  the  upbringing  and 
education  of  children,  should  realize  that  individual  idio- 
syncrasy in  diet  exists  with  children  as  much  as,  if  not  to 
a  greater  extent  than,  with  adults,  and  it  certainly  savours 
of  cruelty,  and  is  at  any  rate  often  very  unwise,  for  reasons 
of  discipline,  to  force  a  child  to  eat  some  article  of  diet  for 
which  it  evinces  a  pronounced  dislike. 

How  difficult  it  often  is  to  settle  on  a  food  or  milk  mixture 
which  absolutely  suits  an  infant  when  the  natural  food 
fails  any  nurse  of  experience  can  tell;  and  it  is  often  found 
that  after  ringing  the  changes  on  various  patent  foods, 
one  of  analytically  poor  food-value  does  best,  where  one 
of  ideal  synthetic  composition  has  ignominiously  failed. 
Metabolic  idiosyncrasy  evidently  begins  very  early  in  life. 

As  old  age  creeps  on,  additional  care  in  the  arrangement 
of  diet  is  needed,  and  almost  invariably  the  amount  of 
butcher's  meat  taken  requires  to  be  greatly  reduced.  In 
those  with  arterial  thickening  and  hypertonus  this  is  of 
special  importance,  and  many  lives  are  shortened  by  the 
tendency  to  "keep  up  the  strength  "  with  nutrition,  often 
meaning  highly  stimulating,  nitrogenous  food.  Lauder 
Brunton  cited  the  case  of  an  ancient  millionaire  whom  he 
put  on  a  pauper's  diet,  chiefly  of  toast  and  gruel,  which 
was  all  his  metabolism  was  equal  to.  On  this  he  lived 
comfortably;  but  possibly  resenting  this  restricted  diet,  he 
changed  his  physician,  and  being  put  on  a  more  generous 
scale  paid  the  penalty  by  an  early  demise. 

The  loss  of  teeth,  from  which  the  majority  of  old  people 
suffer,  is  at  any  rate  suggestive  on  the  part  of  Nature, 
and  possibly  the  substitutes  willingly  furnished  by  the 
prosthetic  dental  surgeon  are  not  unmixed  blessings  if  we 
put  aesthetic  considerations  aside. 

In  old  age  small  meals  are  best,  but  should  consist  of 
light,  protein-free  foods,  with  carefully  chosen  green 
vegetables  (the  coarser  kinds  such  as  cabbage  and  turnips 
being  avoided).  Flatulence  is  the  curse  of  old  age.  Pace 
the  total  abstinence  advocates,  a  small  dose  of  well-matured 
spirit  or  good  wine,  which  Fothergill  described  as  "  the  milk 
of  old  age,"  is  often  of  indisputable  value. 


430        MANUAL  OF  PHYSIO-THERAPEUTICS 

Putting  age  and  occupation  aside,  the  season  of  the  year 
and  the  climate  does  and  must  influence  our  appetite  and 
capacity  for  utilizing  food.  Most  people  consume  and 
really  require  a  larger  proportion  of  food  in  winter  than  in 
summer,  and  on  a  keen  frosty  day  an  amount  of  fat  and  oily 
matter  can  be  consumed  which  would  be  offensive  and 
nauseous  in  summer.  The  love  of  the  Laplander  for  whale 
blubber  and  fat  of  all  kinds  is  notorious,  and  with  the  need 
for  hydrocarbons  which  his  cold  environment  have  occa- 
sioned, he  has  been  endowed  by  Providence  with  the  peculiar 
digestive  activity  for  satisfactorily  utilizing  them.  There 
appears  to  be  110  constant  balance  in  the  human  species 
between  the  amount  of  animal  and  vegetable  food  necessary 
to  sustain  any  individual.  We  recognize  the  average 
individual,  but  we  are  forced  by  clinical  experience  to 
admit  that  there  are  not  a  few  types  and  modifications 
one  way  and  the  other,  or  our  therapeutics  will  be  futile 
in  many  cases.  From  the  type  of  "the  perfect  man," 
physiologically,  there  arc  variants  who,  so  long  as  they 
live  on  food  composed  of  elements  proportional  to  their 
needs,  must  be  regarded  as  normal  individuals.  The  fact 
that  metabolic  diseases  are  almost  peculiar  to  man  shows 
how  common  these  variants  from  the  ideal  type  are,  and 
how  frequently  those  with  individual  peculiarities  suffer 
from  attempting  to  accommodate  themselves  to  the  dietary 
and  habits  suitable  to  the  average  man.  The  proportion 
of  animal  versus  vegetable  food  required  by  them  differing 
from  the  average  standard,  their  efforts  to  conform  to  this 
standard  results  in  imperfect  metabolism  of  either  the  protein 
or  carbohydrate  elements,  and  they  fall  into  ill-health. 
The  man  who  tries  to  convince  his  audience  that  a  diet 
of  nuts,  or  one  free  from  fish  and  meat,  is  the  only  way  to 
physiological  salvation  would  probably  hesitate  to  feed 
a  sheep  on  beef-steak  !  And  yet  the  anomaly  is  no  more 
glaring  than  certain  individuals  attempting  to  maintain 
health  and  bodily  vigour  on  a  strictly  vegetarian  diet. 

On  the  extent  to  which  the  physician  is  able  by  careful 
investigation  on  scientific  lines  to  gauge  the  metabolic  capa- 
bilities of  individual  patients,  and  properly  guide  them  as 
to  their  dietetic  habits,  will  largely  depend  his  success  in 
treating  many  forms  of  disease,  and  especially  chronic  disease. 


CHAPTER  III 
DIET  IN  DISEASE 

IN  disease  the  diet  may  vary  considerably  from  the  normal; 
it  may  have  to  be  increased  above  the  amount  ordinarily 
required  by  the  body,  or  it  may  have  to  be  diminished 
as  regards  all  its  constituent  elements;  or  one  or  more  of 
these,  either  albumin,  fat,  or  starches,  may  require  to  be 
lessened,  or  even  entirely  removed  from  the  patient's 
dietary.  We  require,  therefore,  to  consider  reduced  diet, 
increase  of  diet,  and  special  diet. 

On  the  integrity  of  the  various  digestive  glands  and 
their  proper  supply  with  blood,  and  on  the  normal  condition 
of  the  nervous  system,  will  depend  the  digestion  and 
utilization  of  an  amount  of  food  sufficient  to  maintain 
health. 

The  digestive  function  may  be  affected  in  the  following 
different  ways:  (1)  Functional  or  organic  disease  of  the 
special  digestive  organs;  (2)  any  constitutional  dyscrasia 
or  toxemia;  (3)  by  the  nervous  system  affecting  reflexly 
or  directly  the  mobility,  secretion,  or  blood- supply  of  the 
special  organ. 

Further,  diets  may  have  to  be  modified  owing  to  the 
functional  or  organic  lesions  disordering  metabolism.  The 
digestive  and  assimilative  activity  of  the  cells  in  the  body 
tissues  are  altered,  and  metabolic  activity  lessened;  this 
occurs  in  gout,  diabetes,  and  obesity,  and  may  follow  various 
acute  infective  diseases. 

Hutchison,  who  may  be  regarded  as  one  of  the  greatest 
British  dietetic  authorities  at  the  present  day,  lays  down 
the  following  rules  to  be  observed  in  drawing  up  any  plan 
of  dietetic  treatment : 

1.  When  prescribing  a  diet  for  a  case  of  local  disease,  care 

431 


432        MANUAL  OF  PHYSIO-THERAPEUTICS 

must  be  taken  not  to  sacrifice  the  whole  to  the  part.  The 
organs  are  members  one  of  another,  and  the  patient's 
general  nutrition  must  not  be  interfered  with  in  the  interests 
of  any  one  of  them.  To  avoid  digestive  discomfort  this 
is  too  often  done  in  cases  of  dyspepsia,  and  the  general 
vitality  of  the  patient  lowered  by  too  much  abstemiousness. 

2.  No  article  of  food  must  be  forbidden  without  a  good 
reason  for  doing  so.     Arbitrary  restrictions  must  be  avoided. 

3.  In  acute  disease  one  should  recommend;  in  chronic 
disease  forbid. 

4.  Before  recommending   any  article,  it  is  necessary  to 
ascertain  both  whether  the  patient  likes  it  and  whether  it 
agrees  with  him. 

5.  If  any  special  article  of  food  does  riot  agree  with  the 
patient,  it  is  better  to  reduce  it  than  altogether  cut  it  off 
from  his  dietary. 

6.  General  changes  of  dietary  should  be  made  gradually. 
The   following   are   directions   for   the    diet  and  general 

regulation  of  life  in  certain  diseases,  but  arc,  of  course,  only 
general,  and  need  careful  modification  for  individual  cases : 


Gastric  Disease  and  Insufficiency. 

Formerly  the  diet  for  patients  suffering  from  stomach 
trouble  would  come  under  the  general  heading  of  dyspepsia 
or  indigestion — words  which,  until  recently,  were  used  as 
a  cloak  for  want  of  accuracy  in  diagnosis. 

During  the  past  decade  our  knowledge  of  stomach  disease 
has  been  greatly  enriched,  and  the  analysis  of  gastric  con- 
tents and  use  of  test  meals  have  become  almost  as  common 
as  urinary  analysis. 

Putting  aside  actual  malignant  disease,  we  generally 
recognize  at  the  present  day  the  following  gastric  affections 
which  require  consideration  from  the  dietetic  point  of  view : 
Gastritis  (acute  and  chronic),  gastric  neurasthenia  and 
myasthenia,  hyperchlorhydria  and  hypersecretion,  gastric 
dilatation,  and  gastric  ulcer. 

In  dealing  with  all  forms  of  gastric  disease,  the  problem 
facing  the  physician  is  to  give  sufficient  food  to  allow  for 


DIET  IN  DISEASE  433 

the  nutritive  wants  of  the  organism,  and  at  the  same  time 
to  adapt  the  food  given,  both  in  form  and  quantity,  to  the 
digestive  capability  of  the  patient. 

Acute  Gastritis. — At  first  the  main  indication  is  rest  for 
the  stomach,  and  entire  abstinence  from  food  must  be 
enforced  for  about  twenty-four  hours,  hot  water  being  taken 
in  sips  at  brief  intervals.  This  lessens  the  nausea  and 
washes  out  undigested  debris  from  the  stomach. 

When  the  more  acute  symptoms  have  subsided,  milk  and 
lime-water  or  soda-water,  chicken  broth,  toast-water,  or 
barley-water,  may  be  taken  every  two  hours.  A  gradual 
return  to  normal  diet  is  then  permitted. 

Chronic  Gastritis. — Avoidance  of  all  articles  of  an  indi- 
gestible nature  (see  list,  p.  424),  and  the  taking  of  three 
well-cooked  digestible  meals  and  no  more  in  the  twenty- 
four  hours,  are  indicated.  There  should  be  no  "  snacks  " 
between  meals.  All  highly  seasoned  food,  sauces,  and 
spices,  must  be  studiously  avoided. 

While  the  patient  is  dressing  in  the  morning,  he  should 
sip  a  glass  of  water,  as  hot  as  can  be  taken  with  comfort. 

Hyperchlorhydria. — This  condition  may  be  associated 
with  chlorosis  or  neurasthenia,  and  be  purely  functional  in 
character,  or  it  may  be  a  symptom  of  a  serious  disease, 
hypersecretion,  or  gastro-succorrhoaa  continua  chronica. 

In  either  case  the  dietetic  indications  are  much  the  same. 
Such  patients  are  most  comfortable  with,  and  are  best  able 
to  digest,  a  dietary  which  largely  consists  of  proteid  material. 
Starches  make  them  uncomfortable,  and  are  not  digested. 
Swallowed  saliva  can  scarcely  be  expected  to  exert  any 
diastatic  action  when  there  is  0-5  per  cent,  free  HC1  in  the 
gastric  juice;  nor,  when  the  gastric  contents  pass  on  to  the 
duodenum,  can  the  pancreatic  secretion  act  efficiently.  It 
is  argued  by  some  physicians  that  by  giving  much  proteid 
food  we  are  merely  exciting  increased  secretion  of  HC1, 
already  excessive,  and  they  plead  for  a  modified  starch  diet. 
This  view  is  not  generally  held,  however,  and  personally, 
having  carefully  noted  the  effect  of  starch  diet  on  cases  of 
this  nature  which  have  come  under  my  notice,  I  have 
invariably  found  the  patients  were  made  worse. 

Proteids  enter  into  chemical  combination  with  the  free 

28 


434        MANUAL  OF  PHYSIO-THERAPEUTICS 

acid,  and  alleviate  the  pain  from  which  such  patients  almost 
invariably  suffer. 

All  ill-cooked  and  indigestible  forms  of  meat,  salt  beef, 
and  salt  or  smoked  fish,  should  be  absolutely  avoided,  but 
well-cooked  boiled  or  roasted  mutton  or  beef,  fresh  fish, 
milk,  or  raw  eggs,  should  form  the  larger  part  of  the  food 
taken.  A  limited  amount  ot  altered  starch  food  may  be 
taken,  such  as  Veda  bread,  and  as  improvement  takes  place 
toast,  rusks,  etc.,  may  be  added. 

Strong  tea  or  coffee,  spices,  pickles,  and  sauces,  are  entirely 
objectionable,  and,  indeed,  the  patient  will  usually  volun- 
tarily avoid  them,  as  he  knows  too  well  the  discomfort  and 
pain  which  he  invariably  experiences  after  taking  them. 
Milk  and  soda-water  or  whey  may  be  taken  as  a  beverage, 
and  the  meals  should  be  limited  to  three  in  the  day. 

In  Gastric  Myasthenia  and  Dilatation  of  the  Stomach  the 
indications  are  practically  the  same.  Perhaps  the  most 
important  is  the  limitation  of  fluids.  A  wineglassful  niay 
be  taken  with  each  meal,  and  between  meals  fluid  in  quan- 
tities of  a  wineglassful  or  less  at  intervals  of  thirty  to 
forty  minutes.  If  it  is  not  possible  to  give  the  patient  a 
sufficient  amount  of  fluid  for  the  needs  of  the  organism  in 
this  way,  water  may  be  administered  per  rectum. 

Meals  must  be  small  in  bulk,  digestible,  and  nutritious  in 
character.  Probably  the  best  arrangement  is  to  give  four 
small  meals  at  intervals  of  four  hours  in  the  day.* 

Gastric  Ulcer. — In  the  first  stage,  when  the  ulcer  is  in 
an  active  condition,  complete  rest  in  bed,  with  rectal  alimen- 
tation alone,  is  often  needed. 

After  ten  days  a  diet  of  peptonized  or  plain  milk  may  be 
employed,  and  after  this  has  continued  for  a  couple  of 
weeks  more  solid  food  is  given.  The  milk  may  be  thickened 
by  the  addition  of  cornflour  or  arrowroot,  thin  gruel  or 
lentil  food  may  be  taken,  and  then  chicken  purees,  creamed 
fish,  and,  finally,  tender  meats. 

Gastric  Neurasthenia. — It  is  impossible  to  lay  down 
anything  but  the  most  general  principles  in  the  dietary  to 

*  In  gastric  dilatation  dependent  on  pyloric  stricture,  simple  or 
malignant,  dietetic  treatment  is  mere  temporizing.  Such  cases  are 
surgical  in  their  nature. 


DIET  IN  DISEASE  435 

be  prescribed  for  an  ailment  in  which  the  symptoms  and 
the  personal  factor  differ  so  much.  No  two  cases  of  gastric 
neurasthenia  are  alike.  In  some  there  is  excess  of  hydro- 
chloric acid,  in  others  there  is  a  condition  approaching 
achylia  gastrica.  Further,  the  condition  of  the  gastric 
secretion  varies  much  from  week  to  week,  and  even  from 
day  to  day.  The  general  line  should  be  to  see,  that  the 
patient  takes  a  sufficiency  of  good,  wholesome  food,  whether 
he  suffers  discomfort  after  or  not.  Very  often  the  difficulty 
in  this  class  of  case  is  to  prevent  the  patient  from  leaving 
off  article  after  article  until  he  has  cut  down  his  diet  far 
below  the  limits  of  health,  and  is  actually  perpetuating  his 
disease  by  an  over-restricted  diet. 

Constipation. 

Constipation  is  often  induced  and  perpetuated  by  a  too 
exclusively  nitrogenous  diet,  which  is  too  easily  digested, 
and  leaves  but  little  residue  as  the  result  of  digestion.  A 
normal  amount  of  indigestible  residue  acts  as  a  stimulus  to 
the  mucous  membrane  of  the  intestine.  Further,  if  the 
supply  of  fluid  to  the  blood  be  limited,  less  fluid  is  likely 
to  be  secreted  by  the  intestinal  glands,  and  the  intestinal 
mucous  membrane  becomes  drier.  The  freer  the  supply  of 
water  to  the  blood,  the  more  fluid  the  intestinal  secretions  are 
likely  to  be. 

Articles  Allowed. — Clear  soups;  fish;  meat  of  all  kinds, 
except  veal  or  pork;  game,  ham,  bacon;  bread  (white, 
brown,  or  wholemeal);  choose  the  coarser  breads  with  bran 
or  wholemeal  when  possible.  The  bread  should  be  taken 
in  fairly  large  quantities,  and  the  kinds  varied  from  time 
to  time;  it  should  never  be  new;  the  crust  also  should  be 
eaten.  Toast,  with  plenty  of  butter  or  chipping,  is  good. 
Gingerbread  often  acts  well.  Nuts  are  usually  contra- 
indicated,  but  in  some  cases  Brazil  nuts  or  dry  walnuts, 
well  masticated,  appear  to  help.  Oatmeal,  crushed  oats 
with  sugar  and  milk,  or  golden  syrup,  or  old-fashioned 
treacle ;  cabbage,  cauliflower,  sprouts,  French  beans,  endive, 
celery,  spinach,  salads  with  abundant  oil;  Spanish  onions; 
apples,  stewed  or  baked;  figs,  prunes,  dates,  Normandy 


436         MANUAL  OF  PHYSIO-THERAPEUTICS 

pippins  or  pears,  stewed;  oranges,  grapes,  bananas,  straw- 
berries, gooseberries,  currants,  etc.;  jam,  marmalade, 
preserved  fruits;  hot  or  cold  water;  tea,  always  freshly 
made  and  never  strong  or  taken  with  meat;  coffee,  thin 
cocoa;  beer;  waters,  such  as  Vichy,  Vals,  St.  Galmier, 
Condal,  Pullna,  and  Rubinat. 

Articles  Forbidden. — New  bread  and  pastry;  eggs,  except 
in  moderation  and  lightly  cooked  (best  when  "  scrambled  "); 
peas,  broad  beans,  new  potatoes,  rice,  tapioca,  etc.  (unless 
with  fruit  or  jam  or  honey);  nuts  of  all  kinds;  milk  (except 
in  small  quantities  or  mixed  with  Vichy  or  similar  water); 
sherry. 

General  Directions. — 1.  The  patient  must  be  urged  to  take 
a  full  quantity  of  fluid — for  an  adult  at  least  2|  to  3  pints 
daily.  Many  women  suffering  from  constipation  will  be 
found  to  take  only  1  to  1J  pints  daily;  their  constipation 
often  depends  upon  this  alone,  and  yields  when  a  sufficient 
quantity  of  liquid  is  taken. 

2.  This  fluid  may  well  include  a  tumblerful  of  water,  cold 
or  hot,  immediately  on  getting  out  of  bed  in  the  morning, 
and  a   tumblerful  of   hot  water  at  bedtime.     Where   hot 
water,  with  or  without  a  saline  aperient,  is  ordered  to  be 
taken  in  the  morning,  the  effect  is  often  enhanced  if  it  be 
slowly  sipped  while  dressing. 

3.  No  meat  to  be  taken  with  tea ;  fruit  or  jam,  honey 
or  treacle  with  farinaceous  foods  (e.g.,  blancmange  or  rice,) 
and  order  every  night  or  early  morning  a  full  quantity  of 
such  fruit  as  stewed  figs,  baked  apples,  Normandy  pippins, 
bananas,  etc. 

4.  The  body  should  be  warmly  clothed  to  avoid  the  skin 
getting  chilled,  and  the  feet  kept  warm  and  dry  by  thick 
boots  with  a  cork  or  asbestos  sock. 

5.  Tepid  or   cold   sponging,   followed  by   sharp   friction 
with   a    rough   towel   and   flesh-glove,    daily,    to    secure   a 
vigorous  action  of  the  skin. 

6.  Abdominal    massage    for    ten    minutes   before    rising 
every  morning.     This  (which  can  readily  be  done  by  the 
patient),  followed  by  the  cold  or  hot  water  on  rising,  is  often 
sufficient  to  produce  a  speedy  evacuation. 


DIET  IN  DISEASE  437 


Diarrhoea. 

A  general  dietetic  rule  that  applies  to  all  cases  of  diarrhoea 
is  to  avoid  all  foods  that  leave  much  undigested  residue 
behind  which  would  tend  to  irritate  the  surface  of  the 
intestinal  mucous  membrane. 

The  patient  may  be  allowed  cold  milk  (boiled  for 
preference),  plain  or  peptonized,  alone  or  with  lime-water 
or  barley-water;  koumiss  whey,  white  wine  whey,  albumin- 
water,  rice-water;  soups  (without  vegetables)  thickened 
with  arrowroot,  rice,  sago,  or  tapioca,  and  with  or  without 
brandy  in  addition;  raw  meat,  pounded  meat;  sweetbread, 
tripe;  calf's-foot  jelly;  eggs,  lightly  boiled  or  poached,  or 
beaten  up  with  brandy;  plain  biscuits,  rusks;  gruels,  brandy 
or  port  wine,  whisky  and  water,  or  whisky  and  a  natural 
mineral  water  such  as  Apollinaris  or  seltzer. 

Articles  Forbidden. — Rich  soups  and  meat  essences; 
green  vegetables,  acid  fruits,  nuts,  potatoes;  brown  bread, 
wholemeal  bread;  all  hard  foods,  or  hard  meats,  or  rich, 
fat  meats,  especially  veal  and  pork;  beef  tea,  malt  tea,  malt 
liquors  and  wines. 

General  Directions. — 1.  Warmth  and  absolute  rest  in  bed. 

2.  Warm  clothing,  especially  for  the  abdomen. 

3.  The   food  should  be  given  in   small    quantities    fre- 
quently; it  is  usually  better  given  cold. 

4.  During   convalescence   the  food   should  be  increased 
cautiously. 

Gout. 

Views  as  to  the  etiology  of  gout  have  of  late  years  under- 
gone a  marked,  almost  revolutionary  change,  and  the  part 
played  by  uric  acid  and  its  salts  is  now  regarded  as  a  com- 
paratively unimportant  one.  While  at  the  present  moment 
there  is  complete  absence  of  unanimity  as  to  the  actual 
cause,  there  is  general  agreement  that  derangements  of 
the  gastro-intestinal  tract  constitute  an  important  factor 
in  the  development  of  acute  and  chronic  gout.  It  is  there- 
fore of  essential  importance  to  secure  a  healthy  condition 
of  the  gastro-intestinal  mucous  membrane,  and  a  gouty 


438        MANUAL  OF  PHYSIO-THERAPEUTICS 

patient  can  always  diminish  the  frequency  and  severity  of 
his  attacks  by  a  carefully  arranged  diet,  by  insuring  a  daily 
evacuation  of  the  bowels,  and  by  taking  sufficient  active 
exercise. 

No  single  diet  can  be  regarded  as  suitable  for  all  gouty 
patients,  but  as  a  general  principle  in  many  cases  the  fol- 
lowing articles  are  allowed:  All  fresh  vegetables  freely 
(with  exceptions  named);  fish  (with  exceptions  named);  eggs 
in  moderation,  lightly  boiled  or  poached;  meats  (those  of 
the  lighter  and  whiter  kinds)  in  great  moderation;  rice, 
sago,  and  tapioca ;  fresh  ripe  fruits  (with  exceptions  named) ; 
soups;  toast  or  stale  bread;  potatoes,  salads,  celery,  and 
green  vegetables  (with  exceptions  named) ;  milk,  skimmed, 
diluted  with  Apollinaris,  Vals,  Vichy,  or  seltzer  water; 
lime-juice  freely  diluted;  China  tea,  freshly  infused  and  not 
strong;  coffee,  which  should  be  taken  only  in  moderation, 
and  not  at  night;  cocoa;  tobacco  in  moderation. 

In  small  quantities  only  :  Bread,  plain  biscuits,  potatoes, 
asparagus,  tomatoes,  haricot  beans,  broad  beans,  peas,  and 
lentils;  eggs;  whisky  or  brandy  (not  to  exceed  2  ounces  in 
the  twelve  hours),  unsweetened  gin,  claret,  or  hock,  freely 
diluted;  butter  and  cheese. 

Articles  Forbidden. — Fats  and  rich  foods,  recooked  foods, 
sauces,  rich  gravies  and  made  dishes;  the  harder  or  richer 
meats,  beef,  pork,  or  veal  (as  prepared  in  the  British  Isles) ; . 
smoked,  dried,  or  pickled  fish,  pork,  or  other  meat;  pastry, 
jellies,  sugar;  meat  essences  and  strong  soups;  rhubarb, 
gooseberries,  currants,  strawberries  (except  in  moderation); 
oysters,  mullet,  mackerel,  salmon,  herring,  eel,  lobster, 
crab;  duck,  goose,  hare;  mushrooms,  truffles,  pickles  and 
spices;  preserved  fruits;  ale,  porter,  stout,  port  (usually), 
champagne  (nearly  always),  Burgundy,  sherry,  Madeira, 
and  all  liqueurs. 

General  Directions.  —  1.  Moderation  in  animal  food, 
liberality  in  vegetables.  The  proportion  of  these  must  be 
adapted  to  each  case. 

2.  Abundant  fluid,  of  which  plain  hot  water  (for  prefer- 
ence   slowly    sipped),    night   and   morning,    may    form   an 
important  part. 

3.  Regular  exercise.     A  gouty  patient  should  walk  daily 


DIET  IN  DISEASE  439 

not  less  than  from  three  to  four  miles,  unless  there  be 
reason  to  the  contrary  in  the  individual  case.  Gout,  how- 
ever, is  not  uncommon  in  those  who  take  exercise  freely, 
and  the  degree  and  kind  of  exercise  must  be  carefully 
prescribed  in  each  case. 

4.  Warm  baths,   tepid  or   cold   sponging,    skin  friction, 
massage,  and  Turkish  baths. 

5.  Free  action  of  the  skin,  kidneys,  and  bowels,  regular 
hours,   warm  clothing,   and  the  avoidance  of  fatigue  are 
essential. 

6.  Not  less  than  seven  nor  more  than  eight  hours'  sleep. 
The  patient  should  go  to  bed  early  and  get  up  early. 

Renal  Disease  and  Albuminuria. 

No  rigid  system  of  diet  can  be  formulated  for  all  kidney 
diseases,  nor  for  all  stages  of  any  form  of  nephritis.  In 
determining  the  diet  attention  must  be  directed  for  the  most 
part  to  the  actual  condition  of  the  urine,  but  in  addition 
to  that  other  factors,  such  as  the  patient's  general  nutrition, 
the  presence  of  dropsy,  the  condition  of  the  cardiovascular 
system,  and  the  presence  or  absence  of  ursemic  symptoms, 
must  be  taken  into  consideration. 

When  dropsy  and  uraemia  are  present  in  a  marked  degree, 
the  ordering  of  the  diet  must  be  based  on  the  principle  of 
reducing  the  work  thrown  upon  the  kidneys  as  far  as 
possible,  and  this  is  especially  the  method  to  be  adopted 
in  acute  renal  disease.  Indeed,  in  acute  nephritis  it  is  often 
advisable  to  withhold  all  food  for  a  few  days;  in  subacute 
and  commencing  chronic  cases,  to  allow  only  milk  until  the 
albumin  percentage  is  low.  In  chronic  disease  of  the 
granular  or  "  mixed  "  type,  the  indications  are  to  administer 
food  which  is  readily  assimilable,  will  not  tax  the  digestion, 
and  will  furnish  the  smallest  amount  of  nitrogenous  waste 
calling  for  elimination  by  the  damaged  kidneys. 

The  patient  should  have  a  diet  something  as  follows: 
Soups  thickened  with  arrowroot,  vermicelli,  rice,  or  barley. 
Fish,  fowl,  pigeon,  game,  butter,  cream,  eggs  in  modera- 
tion; green  vegetables,  celery,  onions,  salads,  mushrooms, 
artichokes,  cauliflower,  turnips;  milk  (plain  or  with  alkaline 


440        MANUAL  OF  PHYSIO-THERAPEUTICS 

water  or  peptonized),  skim  milk,  whey,  koumiss,  milk 
diluted  with  rice-water  or  barley-water ;  farinaceous  foods, 
such  as  bread  (stale),  toast,  rice,  tapioca,  vermicelli,  arrow- 
root, sago,  macaroni;  tea,  cocoa,  and  coffee  in  moderation; 
soda-water,  seltzer,  Vichy,  Vals,  Ems,  Salutaris,  plain 
water  (unless  hard);  in  certain  cases  a  little  old  whisky, 
freely  diluted,  or  red  wine  in  small  quantity  and  freely 
diluted  with  water  or  mineral  water. 

Forbidden  Articles. — Sugar,  ices,  pastry,  and  sweet  foods 
generally;  new  bread,  butcher's  meats,  especially  of  the 
brown  kinds;  beef  tea,  meat  essence  and  jellies,  strong 
soups;  recooked  meats,  stews,  hashes;  highly  spiced  food, 
pickles  and  sauces;  rich  foods,  such  as  hare,  duck,  and 
goose;  potatoes,  peas,  and  broad  beans,  except  in  great 
moderation;  cheese;  every  form  of  alcohol  (with  the  occa- 
sional exception  of  those  previously  named). 

General  Directions. — 1.  A  quiet  life  without  worry  or 
excitement. 

2.  A  warm,  dry,  equable  climate. 

3.  Woollen  clothing  next  the  skin  night  and  day  all  the 
year  round. 

4.  Hot-air,  vapour,  or  Turkish  baths;  daily  tepid  spong- 
ing  with    skin  friction.     Avoid  hot   and  cold  baths,   but 
warm  baths  may  be  taken. 

5.  Regular    daily    exercise,    always    stopping    short    of 
fatigue. 

6.  A  free,  regular  action  of  the  skin,  kidneys,  and  bowels 
should  be  maintained. 


Diet  in  Ansemia. 

The  diet  must  often  be  light  and  easily  assimilable  at 
first,  as  the  appetite  is  poor  in  many  cases  and  digestion 
disturbed.  Milk  and  milk  puddings :  concentrated  nutritious 
soups  and  purees;  fish,  chicken,  tripe  (if  not  distasteful  to 
the  patient),  and  sweetbread;  lightly  cooked  eggs  in  various 
forms:  grilled  bacon.  Game,  meat  (scraped,  pounded,  or 
minced)  may  be  add'ed  if  well  borne.  Care  must  be  taken 
to  avoid  too  fluid  a  diet,  as  this  may  hamper  the  digestion; 
but,  on  the  other  hand,  these  patients  are  usually  consti- 


DIET  IN  DISEASE 


441 


pated,  and  should  take  in  the  day  not  less  than  3  pints 
in  small  quantities,  either  in  the  form  of  fluid  foods  or 
water.  A  glass  of  good  Burgundy  at  dinner  or  sound  port, 
while  bitter  ale  or  stout  may  be  taken  at  lunch  if  well  borne. 

Fruit,  ripe  and  fresh  or  cooked,  in  all  forms  is  good,  and 
such  vegetables  as  spinach,  stewed  celery,  Brussels  sprouts, 
and  artichokes,  can  be  given  safely.  The  following  articles 
are  better  left  alone :  pork,  veal,  recooked  meats  vinegar, 
pickles,  and  all  highly  spiced  foods. 

The  iron  percentage  in  various  forms  of  foods  is  important 
to  bear  in  mind,  and  the  following  table  given  by  Bunge  is 
of  interest  (the  figures  are  percentages  in  100  grammes  of 
the  article  mentioned) : 


Spinach 
Oatmeal 
Apples 
Fish  (oysters 
Beef   . . 
Eggs  .  . 


Per  Cent. 

35-9 

Beans 

13-2 

Lentils 

13-2 

Strawberries 

Up  to  84 

Peas   .  . 

4-5  to  16 

Potatoes 

5-7 

Rice    .  . 

Per  Cent. 
7  to  8-3 
8  to  9 
8-9 
6-6 

Up  to  6 
1-3 


Such  a  table  is  suggestive  in  formulating  a  dietary. 

Medicinal  waters,  such  as  Flitwick,  Trefriw,  and  Levico 
(arsenical),  may  be  helpful.  Trefriw  is  the  most  potent 
chalybeate  water  in  Great  Britain,  and  is  sent  out  in  bottles 
from  the  wells  for  home  use. 

As  regards  general  directions,  care  must  be  taken  to 
avoid  exercise  which  overtires,  and  rest  should  always  be 
taken  before  meals.  The  open-air  life  and  sunshine,  when 
obtainable,  is  always  to  be  advocated. 


Arterio-selerosis. 

The  unfortunate  thing  as  regards  dieting  in  this  condi- 
tion is  that  we  are  in  a  measure  merely  locking  the  door 
after  the  steed  is  gone  !  In  many  cases  that  come  into 
one's  hands  the  rise  in  pressure  has  existed  for  some  years, 
the  patient's  arteries  are  thickened,  kidneys  contracting, 
and  the  heart  hypertrophied  to  some  extent.  The  physician 
thus  cannot  cure  the  condition,  but  only  ameliorate  it  so 
as  to  add  to  the  comfort  of  the  patient's  daily  existence 
and  possibly  prolong  his  life. 


442       MANUAL  OF  PHYSIO-THERAPEUTICS 

The  rise  in  blood-pressure,  apart  from  that  due  to  kidney 
trouble  after  scarlatina,  such  as  we  more  commonly  meet 
with  in  the  young,  is  due  to  a  daily  practice  of  overeating, 
and  perhaps  overdrinking  as  well.  There  is  excess  of  food, 
positive  or  relative.  The  fat  man  must  be  reduced,  not 
only  because  he  is  eating  too  much,  and  so  causes  his 
obesity,  but  he  cannot  take  brisk  exercise  while  excessively 
stout.  Not  all  arterio-sclerotics  are  obese,  however,  by  any 
means. 

If  the  blood-pressure  is  excessively  high,  the  food  must 
be  sharply  reduced  to  half  or  even  less,  the  patient  being 
kept  in  bed,  perhaps,  for  six  weeks  while  undergoing  this 
painful  ordeal.  Alcohol  is  a  contributory  agent  to  the 
trouble,  and  will  perhaps  need  complete  elimination  from 
the  dietary,  while  the  amount  of  tobacco  allowed  will 
require  restriction,  the  physician  being  guided  by  the 
character  of  the  pulse  and  presence  of  arrhythmia. 

Nitrogenous  food  it  is,  above  all,  most  important  to  cut 
down,  and  purin-containing  articles  of  diet,  such  as  rich 
soups,  sweetbreads,  hare,  strong  coffee. 

In  many  cases  it  is  best  to  cut  out  butcher's  meat  entirely, 
and  substitute  a  fish,  egg,  and  milk  diet,  with  occasional 
poultry,  rabbit,  pigeon,  or  game  when  in  season.  Cheese 
can  be  taken  freely  if  digested,  and  the  sour-milk  cheese  of 
the  type  of  "  St.  Ivel  "  is  most  wholesome  and  easily 
digested. 

Fruit  can  be  used  freely  as  a  rule — stewed  fruit  at  lunch 
and  dinner,  with  an  apple  in  the  morning;  while  some 
patients  like  and  do  well  on  a  quantity  of  nuts.  The  main 
indications,  therefore,  are  a  drastic  reduction  in  the  amount 
of  food  taken,  often  the  amount  of  liquor  taken,  and  a 
substitution  of  a  milk,  egg,  fruit,  and  vegetable  diet  as 
varied  as  possible. 

Unfortunately,  patients  vary,  and  their  statements  of 
how  much  they  take  cannot  be  relied  on.  Many  subjects 
of  this  disease  are  greedy,  if  not  gluttonous;  they  are 
arterio-sclerotic  because  of  this,  though  this  is  by  no  means 
a  universal  rule.  In  such  cases  the  physician  is  often 
helpless  unless  the  patient  be  treated  in  a  nursing  home. 
If  a  wife  act  as  a  sort  of  food  sentry,  it  does  not  tend  to 


DIET  IN  DISEASE  443 

family  peace.     Some  patients  are  more  easily  dealt  with, 
and  do  not  consider  the  remedy  worse  than  the  disease. 

In  older  patients  with  well-established  arterial  changes, 
granular  kidneys  (probably),  and  a  blood-pressure  of  220  to 
240,  we  are  often  constrained  to  be  complaisant;  it  is  too 
late,  and  drastic  treatment  not  only  makes  the  patient 
miserable,  but  may  be  dangerous.  He  has  got  "  tuned 
up  "  to  the  pressure,  and  it  may  be  kindest  not  to  tell  him 
his  risk. 

Chronic  Cardiac  Disease. 

Owing  to  the  intimate  anatomical  relation  between  the 
stomach  and  the  heart,  care  is  always  needed  as  regards 
the  regulation  of  diet  in  cardiac  patients.  The  overloading 
of  a  stomach  at  a  social  gathering  has  more  than  once  been 
the  last  straw  which  broke  down  a  struggling  heart  and 
brought  the  patient's  life  to  an  abrupt  and  even  tragic 
conclusion.  Gaseous  distension  of  the  stomach  merely 
causes  great  distress  and  embarrassment  in  subjects  who 
have  no  organic  heart  disease,  but  with  a  chronic  cardiac 
patient  is  always  dangerous  and  to  be  avoided. 

Thus,  the  question  of  quantity  of  food  is  as  important 
as  the  quality  almost;  the  meals  must  be  smaller  than  in 
the  average  healthy  man,  and  should  be  dry  in  character, 
little  fluid  being  taken  at  the  time.  Fluids  can  be  taken 
in  the  early  morning  and  before  retiring,  and  in  smaller 
quantities  between  meals. 

Aerated  waters  are  to  be  avoided,  and  also  anything 
likely  to  ferment,  such  as  excess  of  sugar  and  jam,  unripe 
and  overripe  fruit. 

Busks,  toast,  zwieback,  and  crackers  are  preferable  to 
bread,  and  new  bread  is  always  bad  to  take.  Milk  puddings 
properly  cooked,  with  rice  grains,  etc.,  burst,  are  excellent, 
and  in  the  way  of  vegetables  marrows,  stewed  celery, 
spinach,  mealy  potatoes,  and  well-cooked  cauliflower  can 
be  taken. 

Grilled  and  roast  meat  is  always  better  than  anything 
stewed.  Fish,  such  as  salmon,  herring  (fresh  or  cured),  and 
all  shell-fish,  are  best  avoided. 

A  moderate  amount  of  old  spirit,  brandy  or  whisky,  does 


444        MANUAL  OF  PHYSIO-THERAPEUTICS 

good,  helping  both  the  appetite  and  the  digestion.  China 
tea  is  preferable  to  Indian  tea,  and  after-dinner  coffee  is, 
on  the  whole,  omitted. 

In  failing  compensation,  G.  Balfour  laid  down  the  fol- 
lowing rules : 

1.  At  least  five  hours  between  each  meal. 

2.  No  solid  food  between  meals. 

3.  The  solid  meal  of  the  day  should  be  taken  at  1  p.m. 

4.  Meals  should  be  as  solid  as  possible,  not  more  than 
5  ounces  of  fluid  being  taken. 

Tobacco  must  be  used  with  caution,  if  at  all,  but  complete 
withholding  of  it  may  really  embitter  many  men's  existence, 
and  this  has  to  be  borne  in  mind. 


Diet  in  Chronic  Rheumatism. 

It  is  necessary  to  avoid  excess  of  sugars  and  jams  and 
animal  food,  both  of  which  tend  to  lead  to  abnormal  fer- 
mentations and  putrefaction,  with  resultant  auto-toxaemia. 
Excess  of  fruit  is  not  desirable  either,  though  a  moderate 
consumption  of  apples  is  devoid  of  harm.  In  the  cider 
counties  rheumatism  is  by  no  means  a  common  complaint. 
Meat  may  be  taken  once  a  day  in  one  form  or  another,  but 
many  people  do  best  on  a  milk,  egg,  and  vegetable  diet. 
It  is  well  that  the  food  does  not  consist  of  too  many  mixtures, 
and  anything  solid  should  be  well  masticated.  Attention 
must  be  given  to  the  bowels,  and  all  constipation  avoided. 

Different  patients  have  different  digestive  disabilities, 
and  the  question  of  individual  idiosyncrasies  has  to  be  borne 
in  mind. 

Of  fruits,  strawberries  do  not,  as  a  rule,  agree  with  people 
with  an  arthritic  diathesis,  nor  does  rhubarb. 

But  further  than  that,  anything  which  actually  upsets 
the  digestion  will  aggravate  rheumatism,  so  that  quality 
as  well  as  quantity  have  to  be  considered. 

Many  rheumatic  subjects — and  this  is  specially  so  with 
women — drink  too  little  fluid,  which  induces  constipation. 
By  such  patients  more  fluid  than  the  average  should  be 
taken  during  the  day,  beginning  with  hot  water  in  the 
morning.  Some  people  do  better  with  cold  water,  but  it 


DIET  IN  DISEASE  445 

may  seem  heavy  on  the  stomach,  and,  if  cold,  is  more 
digestible  when  aerated.  There  is  no  special  virtue  in 
lithia  water  either  in  gout  or  rheumatism,  in  spite  of  a 
certain  reputation  among  the  laity,  but  it  is  at  any  rate 
harmless. 

Diet  in  Rheumatoid  Arthritis. 

Many  patients  suffer  from  gastro-intestinal  troubles  as 
well  as  their  joints.  The  one  may  be  causative  of  the  other 
condition,  or  aggravate  it.  That  is  to  say,  a  primary  bad 
digestion  may  help  to  induce  the  joint  trouble,  or  the  latter 
disability,  by  restricting  exercise,  may  upset  the  patient's 
digestion  and  further  aggravate  the  joint  trouble — a  vicious 
circle,  in  short.  The  joint  condition  will  not  improve  until 
the  digestion  is  dealt  with.  Food  must  be  carefully  selected, 
well  masticated,  and  given  at  regular  intervals.  Fluids 
should  generally  be  taken  towards  the  end  of  meals,  and 
a  short  rest  both  before  and  after. 

One  of  the  most  fatal  mistakes  in  such  cases  is  to  unduly 
restrict  the  meat  element  in  the  diet.  There  is  quite  a 
widespread  idea  that  meat  is  bad  for  such  patients,  which 
has  no  solid  foundation  on  fact  if  it  be  given  in  reasonable 
quantities  only.  Chalmers  Watson  points  out  that,  if 
pushed,  it  may  do  harm  by  aggravating  pre-existent 
intestinal  putrefaction,  and  this  is  certainly  a  point  of 
importance.  But  sub-nutrition  and  thin  blood  is  commonly 
co-existent,  and  has  to  be  ruthlessly  combated  if  the  patient 
is  to  recover.  The  urine  can  be  watched,  and  excess  of 
urea,  uric  acid,  and  indican  looked  for,  along  with  the 
aromatic  sulphates. 

If  this  be  observed,  a  return  must  be  made  to  a  milk, 
egg,  and  starch  diet.  But,  generally  speaking,  poultry, 
game  (except  hare),  lamb,  beef,  mutton,  and  fat  ham,  with 
white  fish  of  any  sort;  the  heavier  fish  may  be  difficult  for 
some  of  these  patients  to  digest. 

No  restrictions  should  be  placed  on  fresh  green  vegetables 
or  fruits,  if  they  agree.  As  regards  beverages,  tea,  coffee, 
and  cocoa  are  unobjectionable  in  reasonable  strength  and 
quantity,  and  a  good  red  wine  at  dinner,  with  a  glass  of 
sound  ale  at  lunch,  is  worthy  of  all  commendation. 


446          MANUAL  OF  PHYSIO-THERAPEUTICS 

Diet  in  Mucous  Colitis. 

While  special  care  and  precautions  are  highly  necessary 
in  the  treatment  of  mucous  colitis  if  good  results  are  to  be 
obtained,  the  expectations  of  immediate  benefit  from  this 
factor  of  the  treatment  must  not  be  put  too  high  by  the 
patient.  There  are  two  separate  lines  of  dietetic  treatment 
which  can  be  adopted  as  alternatives — the  coarse  cellulose 
diet  advised  by  von  Noorden,  the  irritating  effect  of  which 
on  the  intestine  is  minimized  by  the  addition  of  fat  in  various 
forms.  Other  physicians,  on  the  contrary,  have  urged  the 
employment  of  a  diet  leaving  a  scanty  residue — one  of  a 
bland,  unirritating  nature,  in  short. 

As  a  matter  of  fact,  both  diets  are  useful  in  their  place, 
but  every  case  requires  to  be  judged  on  its  own  merits. 
Modifications  can  be  made  to  suit  different  individuals. 
Some  patients  do  with  a  moderate  cellulose  diet,  except 
that  intolerable  flatulence  is  caused  by  it.  Patients  who 
are  ill-nourished  and  continue  to  lose  weight  require  a 
simple  diet  of  milk,  fat,  and  carbohydrates,  the  cellulose 
elements  being  added  by  degrees.  Their  utilization  of  the 
food  is  promoted  by  the  employment  of  general  massage. 
In  severe  cases,  especially  when  the  patient's  nervous 
system  is  markedly  below  par,  isolation  in  a  nursing  home 
may  be  called  for,  and  a  dietary  somewhat  as  follows  may 
be  employed : 

At  7  a.m. :  Half  a  pint  of  cream  mixture. 

8  a.m. :  Half  a  pint  of  slightly  alkaline  mineral  water, 

effervescing. 

9  a.m. :  Half  a  pint  of  cocoa  with  cream,  2  ounces  of 

bread,  2  ounces  of  butter,  and  some  finely  shredded 
marmalade. 

11.30  a.m. :  Half  a  pint  of  puree  or  milk  soup,  3  ounces 
of  bread,  and  an  ounce  of  butter. 

1  p.m.  Lunch:  Some  shredded  or  scraped  meat, 
2  ounces  of  bread,  riced  potatoes,  some  spinach 
finely  minced,  a  baked  apple,  stewed  fruit  (seed- 
less), and  cream. 

4  p.m. :  Half  a  pint  of  milk-cream  mixture. 


DIET  IN  DISEASE  447 

7  p.m. :  Dinner  as  lunch,  but  a  little  more  bread  or 

toast  and  butter  may  be  taken. 
9.30  p.m. :  Half  a  pint  of  milk-cream  mixture  again. 

This  milk-cream  mixture  is  made  up  of  equal  parts  of 
milk  and  cream,  and  a  teaspoonful  of  sugar  to  each  pint. 
With  the  present  great  shortage  of  milk  and  cream  there 
may  at  times  be  some  difficulty  in  procuring  it. 

The  various  milk  soups  and  purees  should  be  judiciously 
flavoured  from  time  to  time  with  various  vegetables.  The 
meat  taken  is  scraped  from  a  steak  with  a  blunt  knife,  or 
the  steak  finely  minced  and  then  pounded  in  a  mortar. 
It  is  mixed  with  a  little  white  of  egg  and  milk,  placed  in 
a  china  basin,  and  boiled  in  a  "  Gourmet  "  water-bath  or 
double- jacketed  pan  for  about  five  minutes,  being  well 
stirred  the  while. 

The  cellulose  elements  in  the  diet  are  gradually  increased 
—white  bread  is  reduced,  and  brown  or  Graham  bread 
substituted.  Wholemeal  biscuits  are  given  for  variety, 
and  as  the  cellulose  element  is  increased,  so  the  fatty  elements 
in  the  diet  are  increased  in  proportion. 

When  this  diet  is  tolerated  for  some  time,  as  the  mucus 
in  the  stools  diminishes,  a  gradual  return  is  made  to  ordinary 
diet,  including  the  coarser  green  vegetables. 

Alcohol  is  to  be  avoided  in  mucous  colitis,  practically 
doing  harm  in  whatever  form  employed;  this  is  a  point 
De  Langenhagen  emphasizes. 

In  Harrogate  a  special  form  of  biscuits  of  high  protein 
value,  known  as  Caledonian  biscuits,  are  frequently  ordered. 
We  have  personally  given  fish-cream  and  the  finer  kinds  of 
fish  with  acceptance  to  the  patient  and  no  apparent  harm, 
but  it  is  customary  in  Harrogate  to  rule  fish  out  of  the  diet, 
generally  speaking. 

Obesity. 

Unless  the  patient  is  habitually  excessive  in  the  amount 
eaten,  or  unless  the  obesity  be  so  marked  in  degree  as  to 
cause  actual  physical  disability  or  disease,  it  is  best  not  to 
prescribe  any  very  restricted  dietetic  treatment.  Some 
individuals,  though  extremely  stout,  enjoy  excellent  health, 


448        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  a  revolutionary  alteration  in  their  habits  should  not 
be  lightly  undertaken. 

Changes  in  quantity  and  quality  must  be  gradually 
effected.  It  is  unsafe  to  put  any  patient  on  a  very  restricted 
diet  suddenly.  A  weekly  loss  in  weight  of  3  pounds  should 
not  be  exceeded.  Many  diets  have  been  prescribed  by 
many  authorities,  only  differing  in  details.  They  all 
resemble  one  another  in  the  reduced  calorie  value,  the  aim 
being  to  make  up  deficiency  in  this  respect  from  the  fat  of 
the  patient's  tissues. 

Generally  speaking,  something  like  the  following  is 
suitable : 

Articles  Allowed. — Clear  soups  in  small  quantity  only; 
broths,  not  thickened  or  containing  such  ingredients  as 
rice  or  barley;  fish  and  lean  meat  (with  exceptions  named); 
eggs;  fruit;  green  vegetables;  stale  bread,  toast,  rusks,  and 
biscuits  in  great  moderation,  or  gluten  and  almond  bread 
or  biscuits;  butter;  water  (hot  or  cold);  milk  (skimmed), 
diluted  with  Vichy,  Vals,  seltzer,  or  other  natural  water; 
tea  or  coffee,  with  saccharin  instead  of  sugar;  natural 
mineral  waters;  claret,  hock,  Chablis,  whisky  or  brandy,  in 
moderation. 

Articles  Forbidden. — Thick  soups;  eels,  mackerel,  salmon, 
herrings,  sardines  with  oil;  pork,  duck,  goose;  rice,  tapioca, 
macaroni,  oatmeal,  sago,  arrowroot;  potatoes,  peas,  broad 
beans,  parsnips,  carrots,  beetroot;  pastry  and  sweets; 
sugar,  starchy  cocoas;  cream  and  milk,  except  in  great 
moderation;  ale,  porter,  stout,  port,  champagne,  and 
liqueurs. 

General  Directions. — 1.  An  active  life,  with  full  occupa- 
tion, short  hours  of  sleep,  and  the  most  vigorous  exercise 
compatible  with  the  physical  condition.  Cycling,  horse 
exercise,  and  fencing,  are  especially  valuable;  but  the  form 
and  amount  of  exercise  must  be  carefully  adapted  to  each 
case. 

2.  Free    action    of    the   bowels   and    skin,    with   regular 
Turkish  baths. 

3.  The    entire    quantity    of   liquid   taken,    of   all    kinds, 
should  be  moderate. 

(See  also  the  "  Salisbury  "  and  "Banting  "  Systems.) 


CHAPTER  IV 
THE  BANTING  SYSTEM 

Ix  1863  Mr.  William  Banting  published  a  letter  on 
"  Corpulence,"  addressed  to  the  public.  It  was  "respect- 
fully dedicated  to  the  Public  simply  and  entirely  from  an 
earnest  desire  to  confer  a  benefit  "  on  his  fellow-creatures. 
It  was  issued  at  the  price  of  sixpence,  any  profit  yielded 
being  devoted  to  the  Printers'  Pension  Society.  The 
author  spoke  pathetically  of  the  "parasite  of  obesity," 
and  told  how  he  had  just  emerged  from  a  very  long  proba- 
tion in  this  affliction,  and  how  he  hoped  the  publication 
of  this  letter  would  lead  to  the  same  comfort  and  happiness 
he  now  felt  under  the  extraordinary  change.  He  recorded 
that  he  was  sixty-six  years  of  age,  5  feet  5  inches  in  stature, 
and  in  1862  weighed  202  pounds.  He  was  of  active  and 
regular  habits,  and  (as  he  believed)  did  not  indulge  in 
anything  to  excess.  There  was  no  hereditary  tendency  to 
corpulence.  He  had  adopted  increased  bodily  exertion, 
and  especially  rowing,  with,  unfortunately,  development  of 
a  prodigious  appetite,  which  he  was  in  some  degree  con- 
strained to  indulge.  He  tried  fresh  air  and  bathing  and 
Turkish  baths  (ninety);  and  took  "gallons  of  physic," 
"adopted  riding  on  horseback,  the  waters  and  climate  of 
Leamington,  Cheltenham,  and  Harrogate,  and  spared  no 
trouble  or  expense  in  consultations  with  the  best  authorities 
in  the  land."  His  last  state,  however,  was  worse  than  his 
first,  for  he  records  that  he  could  not  stoop  to  tie  his  shoe 
and  had  to  go  downstairs  slowly  backwards.  He  took 
yet  further  advice  from  a  gentleman,  who  left  him  in  a  worse 

\J  o 

plight  than  ever  to  go  for  his  annual  holiday.  ''This," 
said  Mr.  Banting,  "  was  the  greatest  possible  blessing  to 
me."  He  found  another  adviser,  who  dieted  him,  with 
the  result  that  in  about  a  year  he  recorded  that  he  had  not 

449  29 


450          MANUAL  OF  PHYSIO-THERAPEUTICS 

felt  better  in  health  for  the  past  twenty-six  years;  that  he 
had  suffered  no  inconvenience ;  that  he  was  reduced  13  inches 
in  bulk  and  50  pounds  in  weight;  that  he  was  cured  of 
umbilical  rupture ;  that  he  had  sight  and  hearing  surprising 
at  his  age;  and  that  his  other  bodily  ailments  had  become 
mere  matters  of  history.  His  personal  appearance  im- 
proved, he  bore  the  stamp  of  good  health,  ate  and  drank 
and  slept  well,  had  no  indigestion,  left  off  using  boot-hooks, 
and  could  stoop  with  ease  and  freedom.  He  suffered  no 
longer  from  faintness,  and  left  off  his  knee  bandages. 

The  author  of  this  quaint  historical,  clinical  record  states 
that  his  diet  before  treatment  was  bread  and  milk  for 
breakfast,  or  a  pint  of  tea  with  plenty  of  milk,  sugar,  and 
buttered  toast;  meat,  beer,  much  bread,  and  pastry  for 
dinner;  the  meal  of  tea  similar  to  that  of  breakfast,  and 
generally  a  fruit  tart  or  bread  and  milk  for  supper.  The 
diet  ordered  for  him  by  his  adviser,  Mr.  Harvey,  of  Soho 
Square  (whom  he  consulted  for  deafness),  who  learned  it 
from  M.  Bernard's  Paris  Lectures  for  Diabetes,  and  himself 
initiated  it  for  obesity,  forms  the  Banting  cure  as  detailed 
below.  As  Mi1.  Banting  himself  said,  the  remedy  might 
have  been  as  old  as  the  hills,  but  the  application  of  it  was 
of  very  recent  date.  The  forbidden  foods  were  bread, 
butter,  milk,  sugar,  and  potatoes.  The  author's  own  view 
was  that  saccharine  matter  is  the  "great  moving  cause  of 
fatty  corpulence." 

Breakfast  (8  to  9  a.m.):  4  or  5  ounces  of  beef,  mutton, 
kidneys,  broiled  fish,  or  bacon;  cold  meat  of  any  sort  except 
pork;  a  large  cup  of  tea  (without  milk  or  sugar),  a  little 
biscuit,  or  1  ounce  of  dry  toast. 

Dinner  (1  to  2  p.m.):  5  or  6  ounces  of  any  fish  except 
salmon,  any  meat  except  pork,  any  vegetable  except  potato, 
and  1  ounce  of  dried  toast,  fruit  out  of  a  pudding,  any 
kind  of  poultry  or  game,  and  two  or  three  glasses  of  good 
claret,  sherry,  or  Madeira — champagne,  port,  or  beer,  being 
strictly  forbidden. 

Tea  (5  to  6  p.m.):  2  or  3  ounces  of  fruit,  a  rusk  or  two, 
or  a  cup  of  tea  without  milk  or  sugar. 

Supper  (9  p.m.):  3  to  4  ounces  of  fish  similar  to  dinner, 
with  a  glass  or  two  of  claret. 


THE  BANTING  SYSTEM  451 

Nightcap  (when  inclination  directs) :  A  tumblerful  of 
grog  (gin,  whisky,  or  brandy,  without  sugar),  or  a  glass  of 
claret  or  sherry. 

On  the  whole  the  Banting  system  is  sound  in  principle, 
has  the  advantage  of  some  simplicity,  and  forms  the  ground- 
work of  most  obesity  diets  of  to-day.  It  is  unduly  liberal, 
however,  compared  with  many  dietaries  we  have  to  prescribe 
if  patients  are  to  lose  weight.  On  it  a  man  of  moderate 
weight  would  not  probably  become  obese,  but  many  people 
would  keep  their  weight  on  it.  There  is  also  a  risk  with 
certain  subjects  of  so  much  nitrogenous  food  being  a  strain 
on  the  kidneys. 


The  Salisbury  Diet  System. 

The  system  was  first  introduced  by  a  Mr.  J.  H.  Salisbury, 
of  New  York,  who  in  1887  published  a  book  entitled  "  Brief 
Summary  of  the  So-called  Salisbury  Plan  for  the  Treatment 
by  Alimentation  of  the  Various  Diseases  caused  by  Un- 
healthy and  Indiscreet  Feeding."  The  principles  laid  down 
in  the  treatise  have  been  widely  adopted  in  the  treatment 
of  various  morbid  conditions. 

Salisbury's  system  was  intended  to  influence  disease  due 
to  improper  feeding  (obesity,  for  example),  all  arterio- 
sclerotic  conditions,  and  those  associated  with  excessive 
development  either  of  the  connective  or  fatty  tissues,  and 
various  forms  of  dyspepsia.  The  essentials  are  the  taking 
of  hot  water  and  a  diet  consisting  of  about  two-thirds  of 
lean  meat  and  one-third  of  vegetables.  The  water  should 
be  taken  as  hot  as  the  patient  can  bear  it :  1  pint  in  the 
morning  on  rising,  1  pint  an  hour  and  a  half  before  each 
meal  and  half  an  hour  before  bedtime.  It  should  be  slowly 
sipped,  so  that  the  time  taken  in  its  consumption  is  between 
five  and  fifteen  minutes,  and  uncomfortable  distension  is 
avoided. 

If  there  be  thirst  between  meals,  the  patient  may  take 
hot  water  plain,  or  lemon  or  toast  water,  or  "crust  coffee." 
At  meals  5  to  8  ounces  of  clear  tea  or  coffee  are  allowed. 
The  main  food  should  be  the  muscle  pulp  of  beef;  broiled 
or  roasted  lamb  or  mutton;  broiled  beef-steak  or  roast  beef; 


452        MANUAL  OF  PHYSIO-THERAPEUTICS 

oysters  raw  or  broiled  or  roasted  in  the  shell;  broiled  or 
boiled  fish;  chicken  or  game  and  turkey  broiled  or  roasted; 
salt  and  pepper;  Worcester  sauce  and  chutney  in  modera- 
tion; celery  may  be  taken  as  a  vegetable.  All  me^ts  should 
be  fairly  well  cooked  and  taken  regularly,  either  alone  or  in 
company  of  others  taking  the  same  diet, 

It  is  claimed  that  under  this  system  adipose  tissue  will 
rapidly  disappear,  the  loss  cf  weight  being  at  the  rate  of 
10  pounds  to  30  pounds  per  month,  according  to  the  degree 
of  fatness,  the  strictness  of  the  diet,  the  amount  of  exercise, 
and  tho  mental  condition  of  the  patient.  If  the  loss  of 
weight  be  too  rapid,  so  that  the  skin  hangs  in  folds,  such 
food  as  bread,  toast,  rice,  cracked  wheat,  and  potatoes  may 
be  added.  The  loss  of  10  pounds  to  15  pounds  a  month  is 
advocated  as  the  ideal  rate  of  weight  reduction.  When  the 
desired  weight  and  bulk  have  been  reached,  the  fat-forming 
foods  should  be  taken  in  such  proportion  as  may  suffice  to 
maintain  them,  usually  2  parts  of  meat  to  1  part  of  vegetable 
bulk.  It  is  stated  that  the  relish  for  beef  may  become  so 
great  that  from  1  to  2  pounds  may  be  taken  at  each  meal. 

The  body  should  be  washed  twice  daily  with  soap  and 
water,  and  afterwards  rubbed  with  equal  parts  of  glycerine 
and  water.  Regular  exercise,  short  of  fatigue,  should  be 
taken;  or,  where  this  is  impossible,  the  body  should  be  well 
rubbed  from  head  to  foot  for  from  ten  to  twenty  minutes 
three  times  daily.  Flannel  or  silk  should  be  worn  next  the 
skin,  and  the  body  be  kept  comfortably  warm.  All  methods 
calculated  to  maintain  health  should  be  observed. 

The  above  diet  will  cause  most  people  to  lose  weight 
quickly.  Before  advising  anyone  to  rigidly  adhere  to  it, 
howeverr  it  would  be  well  to  exclude  the  existence  of  chronic 
granular  nephritis.  A  dietary  with  so  great  a  proportion 
of  nitrogenous  food  will  tax  severely  any  but  the  healthiest 
kidneys. 

The  Milk  Cure. 

The  milk  cure  has  been  systematically  applied  to  all 
manner  of  ailments,  such  as  the  following:  Dropsies  of  all 
kinds,  cardiac,  renal,  and  hepatic;  obstinate  intestinal 
neuralgias;  incorrigible  dyspepsia  with  grave  disturbances 


THE  BANTING  SYSTEM  453 

of  nutrition;  chronic  colitis;  hepatic  disorders,  such  as 
hypersemia ;  simple  hypertrophy  of  the  liver  and  fatty  liver ; 
asthma,  emphysema;  neurasthenic,  hysterical,  and  hypo- 
chondriacal  states  associated  with  serious  disturbances  of 
nutrition;  and  especially  in  disorders  of  nutrition  dependent 
on  latent  catarrhs  of  the  stomach  and  intestines,  and  also 
on  obesity.  Karell  of  Petrograd  held  the  view  that  the 
methodical  use  of  the  milk  cure  produced  its  effect  as  a 
regulator  of  nutrition,  and  he  maintains  that  it  is  highly 
beneficial  not  only  in  cases  already  enumerated,  but  also 
in  rheumatic  and  gouty  affections,  organic  disease  of  the 
heart,  advanced  renal  degeneration,  and  in  arterio-sclerosis. 

The  milk  used  should  be  well  skimmed — as  creamless  as 
possible — and  it  should  be  obtained  fresh  twice  daily  from 
country-fed  cows.  At  first  the  doses  should  be  small. 
Weir  Mitchell  prescribes  4  ounces  every  two  hours,  and  as 
the  doses  are  increased  the  interval  between  them  is 
lengthened  to  three  hours;  he  also  allows  a  glass  during 
the  night,  to  which  a  little  lime-water  is  added  to  keep  it 
sweet. 

At  the  commencement  3  ounces  to  6  ounces  are  given 
three  or  four  times  a  day,  and  these  doses  are  scrupulously 
adhered  to,  and  no  other  food  is  taken.  The  doses  should 
be  taken  at  equal  intervals,  and  drunk  slowly  in  small 
mouthfuls,  so  that  the  saliva  may  mix  with  it.  Taken  in 
this  way,  it  will  be  readily  digested,  whereas  drunk  ad 
libitum  it  would  cause  indigestion.  In  winter  the  milk 
should  be  warmed  by  standing  the  glass  in  hot  water;  in 
summer  it  should  be  taken  of  the  temperature  of  the 
apartment.  It  should  not  be  boiled,  except  in  rare  cases 
of  diarrhoea. 

If  the  milk  is  well  digested,  as  indicated  by  small  solid 
motions,  the  dose  is  slowly  increased.  The  first  week  is  the 
difficult  one  to  get  over;  during  the  second  week  3|  pints 
a  day  may  be  taken  at  fixed  intervals — viz.,  8  a.m.,  12  noon, 
4  p.m.,  and  8  p.m.  These  hours  may  be  changed,  but  the 
intervals  must  be  maintained. 

When  there  is  great  objection  on  the  part  of  the  patient 
to  its  use,  with  nausea  or  disgust,  Weir  Mitchell  allows  it 
to  be  flavoured  with  a  little  tea,  coffee,  caramel,  or  salt. 


454        MANUAL  OF  PHYSIO  THERAPEUTICS 

He  also  advises  in  certain  cases  that  the  general  diet 
should  be  displaced  slowly  until  the  exclusive  milk  diet  can 
be  tolerated.  When  it  provokes  acidity,  some  alkali  may 
be  added,  such  as  lime-water  or  Vichy  water;  or  it  may  be 
scalded  with  25  per  cent,  boiling  water  and  a  little  carbonate 
of  soda  and  salt  added;  or  a  little  barley  or  rice  water 
may  be  mixed  with  the  milk  to  prevent  firm  clotting.  The 
patients  seldom  complain  of  either  hunger  or  thirst,  but  if 
those  who  are  seriously  ill  attempt  to  take,  instead  of  the 
four  cups  of  skimmed  milk,  four  large  glasses  of  milk  direct 
from  the  cow,  they  will  certainly  not  be  able  to  digest  it, 
and  the  treatment  will  be  discredited.  In  obstinate  sick- 
ness and  diarrhoea  Karell  has  obtained  the  best  results 
from  these  small  doses,  and  he  cites  one  such  case  in  which 
he  gave  only  four  tablespoonfuls  of  skimmed  milk  three 
times  a  day.  No  doubt,  in  a  case  of  this  kind,  the  almost 
absolute  rest  of  the  digestive  organs  which  such  treatment 
affords  is  an  important  agent  in  the  cure. 

Constipation  may  be  regarded  as  a  natural  consequence, 
and  a  sign  that  the  milk  is  absorbed.  It  may  be  remedied 
by  a  simple  enema  of  water,  or  by  a  small  dose  of  castor  oil 
or  rhubarb ;  and  if  obstinate,  a  little  coffee  should  be  mixed 
with  the  morning  milk,  or  some  stewed  prunes  or  a  baked 
apple  may  be  eaten  at  4  p.m. 

Flatulence  is,  as  a  rule,  completely  relieved  by  this  diet; 
if,  however,  any  flatulence  or  diarrhoea  should  be  complained 
of,  it  is  owing  either  to  imperfect  skimming  of  the  milk 
or  to  its  being  taken  in  too  large  a  quantity.  Thirst  may 
be  relieved  by  simple  water  or  seltzer  water. 

If  during  the  second  or  third  week  there  should  be  a  great 
desire  for  solid  food,  a  little  stale  bread  with  salt,  or  a  small 
portion  of  salted  herring,  is  permitted;  and  once  a  day  a 
little  soup  made  with  milk  and  thickened  with  groats. 
After  five  or  six  weeks  some  modification  is  admissible; 
milk,  however,  should  still  be  taken  three  times  a  day. 

It  is  almost  unnecessary  to  point  out  the  importance  of 
combining  rest  with  this  treatment  at  the  commencement, 
for  the  patients  lose  weight  at  first  and  feel  weak  on  account 
of  the  small  amount  taken;  after  long  use,  however,  they 
increase  in  weight.  For  the  first  week  or  two  it  also  causes 


THE  BANTING  SYSTEM  455 

sleepiness.  The  tongue  becomes  covered  with  a  white, 
thick  fur,  and  the  patients  complain  of  an  unpleasant, 
sweetish  taste  in  the  mouth  on  waking.  The  stools  are 
of  a  yellowish  colour,  and  have  a  peculiar  odour.  There 
is  usually  a  large  flow  of  urine,  which  may  exceed  in  quantity 
the  fluid  ingested,  and  so  lead  to  the  removal  of  dropsical 
effusions.  Weir  Mitchell  has  also  observed  that  uric  acid 
disappears  almost  entirely  from  the  urine,  which  assumes 
"a  singular  greenish  tint,"  and  when  hot  nitric  acid  is 
poured  upon  it,  it  no  longer  gives  the  usual  mahogany  tint 
at  the  plane  of  contact;  and  it  would  seem  that  during 
a  diet  of  milk  "  the  ordinary  pigments  of  the  urine  disappear 
or  are  singularly  modified."  The  substances  which  give 
rise  to  the  ordinary  faecal  odours  also  disappear. 

The  changes  here  pointed  out  are  remarkable  indications 
of  the  vast  alterations  in  assimilation  and  the  destruction 
of  tissues  which  seem  to  take  place  under  this  peculiar  diet. 
The  duration  of  the  cure  is  ordinarily  about  six  weeks,  and 
at  the  end  of  this  period  the  quantity  of  milk  should  gradu- 
ally be  reduced  and  solid  food  slowly  introduced  in  the 
place  of  milk  meals,  beginning  with  raw  scraped  beef  and 
stale  bread.  But  for  several  months  the  diet  should  consist 
largely  of  milk.  It  is,  of  course,  well  known  by  all  practising 
physicians  that  quite  a  number  of  people  cannot  take  such 
a  diet,  partly  because  they  are  subjects  of  the  "indigestion 
of  fluids,"  with  gastric  atony  and  the  like,  or  cannot  digest 
it  because  it  upsets  their  liver,  gives  them  a  severe  head- 
ache and  filthy  tongue.  In  such  cases  there  is  little  use 
pushing  the  cure.  A  certain  amount  may  be  digested, 
however,  if  blended  with  cocoa  or  coffee  in  the  form  of 
weak  cafe  au  lait. 

The  Whey  Cure. 

In  many  of  the  Swiss  and  Continental  spas,  and  especially 
in  those  with  saline  springs  where  chronic  catarrh  of  the 
respiratory  organs  is  treated,  such  as  Ems,  Reichenhall, 
and  Ischl,  the  whey  cure  is  employed.  The  whey  is  taken 
warm,  either  alone  or  with  mineral  water  in  definite  quanti- 
ties at  set  times.  Many  physicians  regard  this  practice  as 
in  all  respects  equal  to  the  use  of  skimmed  milk,  and  in 


456  MANUAL  OF  PHYSIO-THERAPEUTICS 

some  cases  preferable,  as  certain  people  find  the  casein  of 
milk  indigestible.  About  20  ounces  a  day  are  taken. 

Irritable  laryngeal  coughs  are  relieved,  and  a  favourable 
influence  is  exercised  over  catarrhal  conditions  of  the 
respiratory  organs  generally. 

It  has  been  found  useful  in  certain  forms  of  dyspepsia, 
intestinal  catarrhs,  and  in  chronic  phthisis.  Whey  acts 
as  a  diuretic,  especially  in  combination  with  saline  mineral 
waters,  and  recent  observations  have  shown  that  lactose 
possesses  distinctly  diuretic  properties. 

It  has  been  recommended  in  the  treatment  of  chronic 
Bright's  disease.  The  "  whey  cure  "  is  not  an  exclusive 
diet  cure,  but  it  is  usual  to  strictly  limit  the  amount  of 
animal  food  taken  and  to  augment  the  fruit  and  vegetables. 
It  adds,  however,  to  the  diet  a  certain  amount  of  milk 
salts  and  milk  sugar.  There  are  various  methods  of  pre- 
paring whey,  but  the  following  is  a  good  one:  Take  |  pint 
of  fresh  milk  heated  to  60-65°  F.,  and  one  and  a  half  tea- 
spoonfuls  of  wine  of  pepsin  or  Fairchild's  essence  of  pepsin, 
and  stir  just  enough  to  mix.  Stand  the  mixture  in  a  warm 
place  until  coagulation  occurs.  Next  beat  up  the  curd 
until  finely  divided,  and  then  strain.  Whey  contains  in 
solution  the  sugar  and  salts  of  milk,  and  also  holds  in 
suspension  a  considerable  portion  of  fat  and  casein  which 
passes  through  the  strainer. 

At  the  health  resorts  mentioned  whey  is  prepared  from 
the  milk  of  the  sheep  and  the  goat,  as  well  as  from  cow's 
milk. 

The  Koumiss  Cure. 

Koumiss,  or  the  fermented  milk  of  the  steppe  mares, 
is  used  as  a  food  and  as  an  intoxicating  beverage  by  all  the 
nomadic  tribes  of  the  south-eastern  steppe  country  of 
Russia. 

The  treatment  in  the  steppes  lasts  two  or  three  months, 
and  is  often  renewed  the  following  summer. 

Annaeff's  establishment  for  the  koumiss  cure  stands  in 
a  park  on  a  hill  on  the  banks  of  the  Volga,  3  versts  distant 
from  Samara.  It  is  provided  with  a  library,  theatre,  and 
other  comforts.  The  koumiss  is  prepared  by  a  Tartar 


THE  BANTING  SYSTEM 


457 


family  in  the  sight  of  the  patients,  and  with  due  regard 
to  cleanliness.  In  its  manufacture  the  milk-sugar  is  con- 
verted into  alcohol,  carbonic  acid,  and  lactic  acid.  The 
casein  is  in  a  state  of  fine  subdivision  most  easy  of  digestion. 

TABLE  OF  THE  RELATIVE  COMPOSITION  OF  SEVERAL 
STRENGTHS  OF  KOUMISS  (STANGE). 


Koumiss — Duration  of  Fermentation. 


Mare's 
Mill,: 

6  Hours. 

IS  Hours. 

30  Hours. 

4  Days. 

Carbonic  acid    .  . 

3-8 

6-0 

7-0 

11-0 

Alcohol 

18-5 

19-5 

30-0 

30-0 

Lactic  acid 

3-9 

5-6 

6-4 

6-4 

Milk-sugar         .  .           51 

18-8 

16-3 

— 

.  — 

Albumin             .  .           23 

22-5 

22-6 

20-0 

16-0 

Fat         .  .          .  .           19 

18-9 

20-0 

19-0 

19-0 

Salts       .  .          .  .             5 

4-5 

4-0 

4-0 

4-0 

An  analysis  of  koumiss  made  in  Moscow  after  two  days' 
fermentation  gave:  Alcohol,  1-65  per  cent.;  fats,  2-05; 
milk-sugar,  2-20;  lactic  acid,  1-15;  finely  divided  casein, 
142;  salts,  0-28;  carbonic  acid,  9-70.  Dr  Stange  came  to 
the  conclusion  that  "  favourable  results  "  can  only  be 
obtained  from  the  koumiss  cure  on  the  steppes,  seeing  that, 
besides  the  employment  of  genuine  koumiss,  a  hot  and  dry 
climate  is  absolutely  necessary."  He  found  it  specially 
beneficial  in  respiratory  catarrhal  conditions,  and  also 
catarrh  of  the  gastric  mucous  membrane.  It  was  found  of 
service  also  in  the  early  stages  of  phthisis,  as  well  as  in 
conditions  of  general  malnutrition,  such  as  anaemia,  malarial 
cachexia,  and  scrofula. 

Artificial  koumiss  is  prepared  in  England  by  the  Ayles- 
bury  and  other  dairy  companies.  But  undoubtedly  the 
best  koumiss  is  to  be  obtained  on  the  steppes,  and  the  best 
results  follow  its  use.  Prior  to  the  war,  at  any  rate,  institu- 
tions existed  both  at  Moscow  and  Petrograd  where  koumiss 
from  steppe  mares  could  be  obtained.  A  factor  of  import- 
ance in  the  cure,  however,  is  the  delightful  summer  climate 


458        MANUAL  OF  PHYSIO-THERAPEUTICS 

of  the  steppes,  which  seems  specially  suited  for  pulmonary 
cases;  the  winters  are  severe,  on  the  other  hand.  The 
people  who  are  normally  resident  there  seem  to  have  com- 
pletely mastered  the  art  of  the  making  of  koumiss,  though 
its  composition  is  by  no  means  stable.  It  is  rich  in  milk- 
sugar  and  comparatively  poor  in  casein  and  fats. 

Large  quantities  of  koumiss  can  be  easily  digested,  and 
it  has  been  observed  to  exert  a  diuretic  or  diaphoretic 
action  according  to  whether  the  external  temperature  is 
high  or  low;  weight  is  usually  gained,  and  many  cases  of 
phthisis  have  been  reported  cured  in  the  Samara  and 
Orenberg  steppes. 

A  special  breed  of  mares  is  used — light- coloured,  un- 
broken beasts,  pasturing  in  the  steppes  near  mountain 
ranges,  where  they  get  running  water  and  salt  teds.  They 
should  be  able  to  bathe  frequently,  and  must  not  have 
hay  or  oats. 

There  are  two  kinds  of  koumiss  made — one  light-coloured 
and  slightly  fermented,  the  other  strong  and  highly  fer- 
mented. 

The  patients  are  made  to  rise  early  and  take  a  glass  of 
koumiss  every  half-hour,  except  the  two  hours  preceding 
supper  and  dinner.  Meats  and  fats  form  the  chief  part 
of  the  ordinary  food ;  sweets,  fruits,  and  salads  are  avoided, 
as  well  as  coffee,  ices,  and  spirits.  Lime-water  is  used  to 
arrest  the  diarrhoea  koumiss  so  often  causes.  At  first  a 
few  glasses  only  are  taken,  so  as  to  accustom  the  patient  to 
the  cure;  although  the  diarrhoea  has  to  be  guarded  against, 
most  patients  digest  it  well;  it  relieves  constipation,  more- 
over, and  acts  as  a  diuretic.  The  patients  gain  in  weight 
and  show  signs  of  increased  blood-formation.  Doubtless 
the  cure  is  helped  by  ample  exercise  in  the  open  air. 

Good  koumiss  is  a  milky-looking,  frothy  fluid  with  an 
agreeable,  slightly  acid  taste,  containing  about  1  per  cent, 
of  alcohol  and  lactic  acid.  Its  ease  of  digestion  is  partly 
attributed  to  the  stimulating  effects  of  the  alcohol  on  the 
digestive  secretions;  the  amount  is  too  small  to  cause  any 
intoxication,  however.  It  usually  makes  the  patient  feel 
drowsy  and  languorous,  but  in  some  subjects  acts  as  an 
aphrodisiac. 


THE  BANTING  SYSTEM  459 


The  Grape  Cure. 

The  grape  cure  is  another  dietetic  cure  of  which  a  brief 
account  must  be  given  here.  The  nutritive  value  of  grapes 
is  not  great ;  they  contain,  however,  much  sugar  as  well  as 
potash  salts.  They  are  an  agreeable  form  of  food,  and 
afford  a  therapeutic  measure  at  our  disposal  between  nutritive 
substances  on  the  one  hand  and  medicinal  substances  on 
the  other.  Much  of  the  benefit  referred  to  this  cure  may 
be  doubtless  more  properly  attributed  to  the  climatic 
advantages  of  such  localities  as  Meran  and  Montreux, 
where  the  cure  is  taken.  The  effect  of  the  cure  is  aided 
by  a  supporting  diet  of  nutritive  character.  Pulmonary 
patients  should  not  take  more  than  an  average  of  2  pounds 
of  grapes  a  day,  beginning  with  a  pound;  other  patients 
should  not  exceed  4  pounds.  In  cases  of  gastric  catarrh 
3  pounds  a  day  may  be  eaten,  the  diet  at  the  same  time 
being  carefully  regulated.  Constipation,  with  hepatic  con- 
gestion and  "abdominal  plethora,"  may  be  benefited  by 
3  pounds  to  4  pounds  daily;  and  in  these  cases  the  dose 
may  exceptionally  be  increased  to  5  or  6  pounds.  The 
laxative  influence  of  4  pounds  to  6  pounds  of  grapes  eaten 
daily  has  been  found  beneficial  in  hsemorrhoidal  affections, 
and  in  cardiac  diseases  with  a  tendency  to  visceral  con- 
gestion and  venous  engorgement,  in  hypersemia  of  the  liver, 
and  in  chronic  constipation. 

The  tendency  of  the  renal  and  hepatic  concretions  is 
often  advantageously  modified  by  this  cure.  It  is  best  to 
begin  with  |  pound  of  grapes  in  the  morning  fasting  (or 
an  hour  or  two  after  a  light  breakfast  if  they  disagree  when 
taken  fasting),  and  another  |  pound  at  5  p.m.  After  two 
or  three  days  a  third  |  pound  should  be  taken  between 
11  and  12  noon.  Little  by  little  the  dose  is  increased  to 
about  a  pound  each  time.  In  other  cases  which  bear  the 
cure  well  larger  quantities  may  be  prescribed.  In  some 
cases  of  dyspepsia  a  bunch  or  two  at  dessert  may  be  sub- 
stituted for  the  midday  dose. 

The  aperient  effect  may  not  be  manifest  at  first,  but  it 
usually  shows  itself  after  a  few  days. 


460        MANUAL  OF  PHYSIO-THERAPEUTICS 

Figs  and  pears  are  also  permitted  with  the  cure  at  Meran, 
in  order  to  diminish  the  repugnance  of  one  kind  of  fruit 
alone. 

Some  irritation  of  the  gums  is  apt  to  be  excited  during 
the  cure ;  this  may  be  relieved  by  rinsing  the  mouth  with 
cold  water  to  which  a  little  bicarbonate  of  soda  is  added. 
It  has  also  been  recommended  that  the  patient  should, 
while  eating  the  grapes,  take  from  time  to  time  a  small 
piece  of  fine  white  bread  to  remove  any  portion  of  the  fruit 
adhering  to  the  teeth. 

Towards  the  end  of  the  cure,  which  lasts  from  four  to 
six  weeks,  the  quantity  of  grapes  should  be  gradually 
diminished. 

The  main  composition  of  grapes,  according  to  Koenig, 
is — Water,  7847  per  cent.;  sugar,  14-36;  free  acid,  0-79; 
nitrogenous  extractives,  1-96;  stones  and  woody  fibre,  3-60; 
total  ash,  0-53.  The  ash  consists  chiefly  of  potash  salts, 
together  with  salts  of  lime  and  magnesia. 

The  grape  cure  may  prove  beneficial,  and  is  prescribed 
with  success  in  those  cases  of  "abdominal  plethora" 
associated  with  a  deposition  of  much  superfluous  fat;  much 
of  this  fat  may  be  removed  if  the  laxative  influence  of  the 
grapes  is  aided  by  a  spare  diet  in  which  the  fats  and  carbo- 
hydrates are  strictly  limited.  It  cannot  be  credited  with 
any  real  curative  influence  in  phthisis,  but  it  appears  to  be 
useful  in  cases  of  chronic  bronchial  catarrh  and  emphysema, 
and  has  been  found  beneficial  in  cases  of  gastric  and  intestinal 
catarrh  in  anaemic  persons,  in  vesical  catarrh,  in  gouty 
concretions,  and  in  cases  of  malarial  cachexia. 

The  Soured  Milk  Diet. 

We  largely  owe  the  popularization  of  this  diet  and  method 
of  treatment  to  the  late  M.  Metchnikoff,  of  the  Pasteur 
Institute,  Paris.  Nine  years  ago  it  became  a  craze,  and 
everybody  was  taking  it.  It  has,  of  course,  been  a  staple 
article  of  diet  in  the  Near  East,  especially  in  Bulgaria,  for 
hundreds  of  years,  and  is  there  known  under  the  name  of 
"yorghourt." 

In  1910  the  writer  prescribed  it  very  largely,  and  had  it 


THE  BANTING  SYSTEM  461 

made  in  considerable  quantities  daily  by  means  of  an 
electric  oven.  It  is  now  much  less  in  vogue,  as  the  whole 
thing  was  overdone,  and  through  the  much-advertised 
illness  of  a  well-known  actress,  due  to  taking  a  "  bad  brew," 
so  far  as  society  went,  the  thing  for  the  time  received  a 
death-blow. 

This  is  no  new  experience  with  new  forms  of  treatment, 
and  in  no  way  detracts  from  the  real  value  of  the  soured 
milk.  It  is  probably  one  of  the  most  effective,  if  not  the 
most  effective,  method  of  combating  intestinal  toxaemia 
along  with  constipation.  The  main  agent  concerned  is  the 
bacillus  of  Massol,  which  generates  free  lactic  acid  and 
combats  the  formation  of  butyric  acid  and  putrefaction 
generally. 

This  has  been  clearly  demonstrated  by  Herter  of  New 
York  and  other  workers.  Metchnikoff  popularized  and 
placed  on  the  market  a  tabloid  preparation  known  as 
"  Lactobacilline,"  which  was  stated  to  contain  the  live 
germs  and  was  taken  either  with  milk  or  eau  sucree.  This 
started  the  growth  of  the  germ  in  the  intestine,  and  it  con- 
tinued to  multiply  long  after  the  administration  ceased. 
Undoubtedly  the  best  way  to  produce  this  effect,  however, 
was,  under  proper  precautions,  to  prepare  milk  from  a  pure 
strain  of  the  B.  Massol  obtained  from  a  reliable  laboratory, 
and  day  by  day  to  continue  the  souring  of  fresh  milk  by 
means  of  subcultures.  This  was  our  practice.  The  milk 
is  pleasant  to  take,  with  a  sharp  taste,  rather  refreshing 
than  otherwise,  and  ameliorated  by  the  addition  of  sugar 
and  some  cinnamon  powder. 

Ordinary  buttermilk  is  taken  by  some  people  for  the 
same  reason,  but  is  devoid  of  fat  and  of  comparatively  low 
nutritive  value.  When  milk  is  soured,  the  casein  is  rendered 
soluble  to  a  large  extent,  while  the  phosphate  of  lime  has 
its  solubility  increased.  The  curds  thus  cause  no  digestive 
upset  if  taken  in  reasonable  quantity. 

In  certain  conditions  remarkable  results  have  been  ob- 
tained: for  instance,  in  children  with  severe  gastro-intestinal 
catarrh;  in  chronic  gastric  catarrh  and  intestinal  putre- 
faction with  pultaceous  stools  in  adults,  also  in  gout, 
rheumatism,  and  chronic  nephritis. 


462        MANUAL  OF  PHYSIO-THERAPEUTICS 

It  is  of  special  value  where  the  proteins  are  not  digested 
adequately,  but  is  practically  valueless  in  carbohydrate 
fermentation.  While  at  present  rather  lost  sight  of,  it  is 
not  a  treatment  which  should  be  forgotten.  From  most  of 
the  large  dairy  companies  the  soured  milk  can  be  regularly 
obtained  in  sealed  jars,  and  the  home  preparation  is  not 
by  any  means  a  difficult  matter. 


Dried  Milks  and  Casein  Foods. 

We  can  hardly  leave  the  subject  of  milk  cures  without 
reference  to  these  valuable  dietetic  articles,  which  have  come 
into  vogue  of  late  years,  and  been  so  useful  in  dealing  with 
patients  whom  milk  upsets  and  makes  bilious.  They  are 
sold  under  various  names — the  original  Sanatogen  (first 
made  in  Germany),  Ceregen,  Bynogen,  and  other  fancy 
names. 

They  are  unquestionably  of  real  merit  as  extra  food,  and 
in  certain  subjects  we  have  again  and  again  noted  the 
steady  increase  in  weight  and  nerve  tone  when  they  were 
used. 

Some  neurasthenics  have  a  tendency  to  constant  loose- 
ness of  the  bowels,  and  this  is  very  often  checked  by  the 
administration  of  these  foods.  On  the  other  hand,  those 
folk  who  suffer  from  "  dura  ilia  "  find  their  ailment  aggra- 
vated, and  if  prescribed  they  must  be  accompanied  by  some 
laxatives  or  malt. 


CHAPTER  V 
DIABETES 

THE  principle  to  be  kept  in  view  in  ordering  the  food  of  a 
diabetic  patient  is  that  by  mainly  protein  and  fat  diet 
the  excretion  of  sugar  in  slight  cases  can  be  entirely  sus- 
pended, and  in  severe  cases  kept  at  a  very  low  figure. 

So  far  as  is  practicable,  therefore,  fats  and  albuminates 
should  form  the  sole  food  of  the  patient.  The  more  severe 
the  nature  of  the  case,  the  more  rigid  the  adherence  to  this 
rule  should  be. 

It  will  be  found  essential,  however,  to  have  some  regard 
to  the  feelings  and  wishes  of  the  patient.  Some  will  almost 
invariably  resent  being  placed  on  a  diet  composed  exclusively 
of  fats  and  meat,  and  apart  from  their  wishes  such  a  diet 
may  be  actually  injurious  to  them  when  used  exclusively. 
Certainly,  present  opinion  is  that  sudden  withdrawal  of  all 
starches  tends  to  bring  about  the  always  dreaded  condition 
of  acetonamiia.  There  is  an  inclination  just  now  to  allow 
the  patient  a  limited  amount  of  bread-stuff,  toasted  prefer- 
ably, and  this  is  well,  for  the  most  difficult  problem  in  the 
dieting  of  diabetics  has  ever  been  to  find  some  substitute 
for  bread  which  is  at  once  palatable,  easily  prepared,  and 
inexpensive. 

A  dietary  somewhat  as  follows  may  be  regarded  as  in 
agreement  with  the  views  of  most  physicians  at  the  present 
time : 

Ceteris  paribus,  patients  are  allowed — All  clear  soups 
and  broths;  fish  of  all  kinds  (except  cod's  liver),  including 
shell-fish  (with  plain  melted  butter  only):  meats  of  all 
kinds;  eggs  in  all  forms;  cream,  butter,  cheese,  gluten, 
bran  and  almond  breads  and  biscuits;  greens,  spinach, 
broccoli,  turnip-tops,  watercress,  mushrooms,  mustard 

463 


464        MANUAL  OF  PHYSIO-THERAPEUTICS 

and  cress,  cucumber,  lettuce,  tomatoes,  celery  (sparingly), 
endive;  French  beans,  cauliflower,  and  asparagus  (the 
green  part),  all  in  great  moderation;  strawberries,  goose- 
berries, raspberries,  currants,  peaches,  and  nectarines,  in 
very  small  quantity,  and  occasionally  only;  oranges  and 
lemons;  nuts  of  all  kinds,  except  chestnuts;  pickles,  olives, 
vinegar,  oil  jelly  (sweetened,  if  preferred,  with  "  saxin  " 
or  laevulose);  whipped  cream,  custards;  koumiss,  milk  in 
great  moderation;  tea,  coffee,  cocoa  (nibs);  claret,  hock, 
dry  Sauterne,  Chablis,  Burgundy,  brandy,  and  whisky; 
soda-water,  Apollinaris,  seltzer,  Contrexeville,  Vichy,  Vals, 
or  St.  Galmier  waters;  saccharine  or  laevulose  as  a  sweetening 
agent.  Any  alcohol  should  be  ordered  in  great  moderation. 

Articles  Forbidden. — Sugar  and  starch  in  any  form,  bread 
and  biscuits  (unless  in  small  quantity  when  specialty 
directed);  rice,  tapioca,  sago,  vermicelli,  arrowroot,  corn- 
flour, oatmeal;  potatoes,  peas,  broad  beans,  parsnips, 
beetroot,  carrot,  Spanish  onions;  pastry  and  puddings  of 
all  kinds;  fruits  of  all  kinds,  fresh  or  preserved,  except 
those  named  (in  moderation  only);  milk  (except  in  small 
quantity),  ale,  stout,  porter,  port,  champagne,  liqueurs,  and 
cider.  No  flour  should  be  used  in  the  frying  of  food  for 
diabetic  patients.  Of  breads  specially  made,  Bruisson 
Jeune  is  one  of  the  best. 

General  Directions. — 1.  Regular  daily  exercise  is  extremely 
important,  but  fatigue  should  be  avoided. 

2.  Flannel  clothing  next  the  skin  always,  most  carefully 
guarding  against  "catching  cold." 

3.  A  calm,  equable,  regular  life,  with  good   hours,  and 
without  worry  or  excitement  or  overwork. 

4.  Regular  action  of  the  skin  should  be  encouraged  by 
tepid  sponging,  followed  by  skin  friction,  by  warm  bathing, 
massage,  and  Turkish  baths. 

It  is  usually  the  better  practice  to  gradually  lessen  the 
carbohydrate  foods  until  the  sugar  has  disappeared,  and 
afterwards  to  tentatively  replace  them,  noting  the  effect  of 
each  addition  as  a  guide. 


DIABETES  465 

The  Allen  Treatment  of  Diabetes. 

This  is  a  modification  of  the  Guelpa  cure. 

For  the  first  two  days  the  patient  is  put  upon  a  diet 
containing  a  minimum  of  fat.  The  following  is  an  average 
day's  regime  as  regards  diet : 

Breakfast:  12  ounces  of  coffee,  2  ounces  milk,  an  egg, 
and  4  ounces  of  raw  lettuce. 

Lunch:  8  ounces  of  clear  soup,  29  ounces  of  lean  meat, 
and  8  ounces  of  cooked  cabbage. 

Tea :  12  ounces  of  tea,  with  an  ounce  of  milk,  and  a  few 
radishes. 

Dinner :  8  ounces  of  clear  soup,  2  ounces  of  sole,  turbot, 
or  plaice,  an  egg,  8  ounces  of  stewed  celery,  and  an  orange. 

At  the  end  of  these  two  days  the  patient  remains  in  bed, 
and  is  nursed  as  if  recovering  from  a  severe  illness.  He  is 
protected  from  worries,  any  mental  exertion,  and  the  visits 
of  friends.  He  is  allowed  to  get  up  for  a  morning  bath 
and  to  go  to  the  lavatory.  Metabolism  is  thus  reduced  to 
a  minimum,  and  a  condition  of  almost  metabolic  stasis 
brought  about,  so  that  the  patient  loses  a  minimum  of 
weight  during  the  period  of  very  restricted  diet. 

The  patient  is  also  under  the  immediate  control  and 
observation  of  the  physician  or  his  assistants.  He  may 
drink  as  much  water,  plain  or  aerated,  as  he  wishes,  but  it 
must  all  be  measured  before  consumption.  Care  must  be 
taken  to  insure  an  action  of  the  bowels  once  a  day  at  least. 
An  effervescing  saline — seidlitz  powder,  a  few  ounces  of 
Apenta,  or  the  like — usually  secures  this,  but  if  need  be 
castor  oil  is  given  as  well,  or  recourse  had  to  a  Higginson 
syringe. 

For  a  period  of  twenty-four  hours  after  the  urine  has 
become  free  of  sugar  the  patient's  diet  is  carefully  restricted 
to  weak  tea,  coffee,  or  clear  beef  tea.  Every  care  should 
be  taken  to  have  these  nicely  prepared  and  served  hot,  so 
as  to  be  palatable  to  the  patients.  Diabetics  are  naturally 
short  in  the  temper,  and  "  do  not  suffer  fools  gladly." 
Unpleasantness  is  thus  avoided,  and  the  patient  spared 
petty  irritation,  which  the  boredom  and  severity  of  the 
treatment  render  him  specially  liable  to  resent. 

30 


466        MANUAL  OF  PHYSIO-THERAPEUTICS 

Cups  and  glasses  of  known  capacity  should  be  used,  so 
as  to  avoid  cooling  off  fluids  by  specially  measuring  them. 

Alcohol  is  not  necessarily  avoided;  indeed,  if  the  patient 
has  been  in  the  habit  of  "taking  his  whack,"  he  may  be 
indulged  to  the  extent  of  two  or  three  glasses  a  day — of 
59  per  cent,  under  proof. 

For  the  beef  tea,  Liebig's  extract,  Mosquera  beef  jelly, 
or  similar  preparations,  are  handy. 

At  least  8  ounces  of  weak  tea,  coffee,  or  beef  tea,  are 
given  four  times  daily.  It  is  useless  to  specify  "  at  dinner," 
etc.,  as  there  is  no  meal  in  the  ordinary  sense. 

The  urine  passed  in  the  twenty-four  hours  is  collected, 
beginning  at  8  a.m.  For  detecting  sugar  Leyton  recom- 
mends the  following  (Benedict's)  test:  Get  a  solution  of 
copper  sulphate,  18  grammes;  sodium  citrate,  299  grammes; 
and  water  to  1,000  c.c.  Boil  10  c.c.  of  this  for  two  minutes 
with  20  drops  of  the  urine,  and  allow  the  mixture  to  cool. 
If  cloudiness  or  any  sort  of  a  precipitate  develop  within  a 
quarter  of  an  hour  after  cooling,  sugar  may  be  regarded  as 
present. 

As  a  corroborative  test  we  use  an  alkaline  solution  of 
sodium  nitrophenyl  propiolate,  which,  when  boiled  with  the 
urine  containing  sugar,  forms  indigo. 

The  essential  factor  to  realize  is  that  the  diet  as  above 
must  be  continued  until  the  sugar  has  been  absent  from 
the  urine  for  twenty-four  hours.  It  is  manifest  that  treat- 
ment of  this  kind  cannot  be  properly  carried  out  except 
in  a  hospital,  nursing  home,  or  institution  of  some  sort. 

After  the  fasting  period  described  above  and  the  dis- 
appearance of  the  sugar,  fcod  is  given  in  increasing  amounts, 
with  a  view  to  establishing  the  tolerance  of  the  patient  for 
carbohydrate,  proteid,  and  fat.  The  starch  given  is  in 
such  a  form  that  it  is  freely  mixed  with  cellulose  and  thus 
slowly  absorbed.  Bread  is  unsuitable  for  this  purpose,  but 
use  is  made  of  asparagus,  French  beans,  and  sea-kale. 
When  cooked,  these  contain  less  than  3  per  cent,  of  starch, 
and  a  commencement  is  made  with  250  grammes,  which 
means  5  grammes  of  pure  starch.  To  make  the  treatment 
tolerable,  it  is  necessary  to  add  after  the  third  day  a  little 
fat  and  a  gradually  increasing  amount  of  proteid. 


DIABETES  467 

By  the  tenth  day  the  patient  is  taking  something  like 
the  following,  ceteris  paribus  : 

Breakfast:  |  pint  of  coffee  and  1  ounce  of  thin  cream, 
an  egg,  1  ounce  of  cooked  bacon  fat,  and  7  ounces  of  raw 
lettuce. 

Lunch:  1|  ounces  of  cooked  lean  meat,  \  ounce  of  fat, 
3|  ounces  of  cooked  sea-kale  or  beans,  1|  ounces  of  boiled 
potatoes. 

Tea :  |  pint  of  weak  tea,  1  ounce  of  thin  cream,  an  egg, 
and  |  ounce  of  boiled  potatoes. 

Dinner :  8  ounces  of  consomme,  1  egg,  4  ounces  of  cooked 
cabbage,  and  2|  ounces  of  cooked  sea-kale  or  French  beans. 

Calorie  value  =952. 

The  response  of  each  patient  to  such  diet  will  vary  greatly, 
sugar  frequently  returning  in  some  degree  as  the  carbo- 
hydrate factor  is  increased  or  too  much  proteid  taken.  If 
sugar  returns  after  the  fifteenth  day,  while  the  carbo- 
hydrate is  being  increased,  but  proteid  has  been  kept 
constant,  it  is  an  indication  that  the  carbohydrate  limit 
has  been  passed.  A  further  period  of  fasting  is  indicated. 
If  the  sugar  returns  before  the  sixth  day,  both  skill  and 
patience  are  needed  both  on  the  doctor's  and  the  patient's 
part.  Patients  must  be  warned  not  to  worry  about  their 
weight,  and  the  carbohydrate  may  have  to  be  reduced  to 
below  10  grammes,  but  an  adequate  amount  of  proteid 
given. 

The  optimum  diet  is  arranged  when  it  is  found  the  patient 
keeps  free  of  sugar  in  his  urine,  and  keeps  his  weight,  or 
even  starts  to  gain  a  few  ounces  a  week;  rapid  gains  must 
not  be  looked  for. 

In  the  main  the  results  obtained  are  much  better  than 
by  any  previous  method  of  treatment.  Leyton  states  that 
at  the  London  Hospital,  of  66  diabetics,  39  were  treated 
by  this  method,  and  29  left  sugar-free  and  taking  a  diet 
of  about  2,000  calories.  Of  the  27  treated  by  other  methods, 
3  only  left  sugar-free. 


INDEX 


ABDOMEN,  (')inpress  for,  119 
massage  of,  165 

neuroses  of,  fango  baths  in,  149 
Abdominal    bandage,    or    Neptune's 

Girdle,  120 
Abstinence,  total,  421 
Accumulators,  272-275 

management  of,  275 
Acid,  free,  percentage  of,  in  fruits,  413 
Acid-intoxication,  electric  light  baths 

in,  45 

Active  movements,  175 
Air,   composition   of,    in   various   cli- 
mates, 257 

Aix  douche,  103,  104,  105 
Albumin,  caloric  value  of,  409 

percentage    of,    in    cereals    and 

vegetables,  412 
in  dairy  products,  411 
in  fish,  413 
in  fruits,  413 
in  meats  and  game,  411 
in  soups  and  beverages,  412 
Albuminuria,  climates  favourable  in 

treatment  of,  261 
diet  in,  439,  440 

Alcohol,  dietetic  properties  of,  421 
in  koumiss,  457 

percentage  of,  in  various  bever- 
ages, 422 
rub,  the,  231 
value  of,  in  old  age,  42!) 
Alcoholic  beverages,  421 
Allen  treatment  of  diabetes,  465-467 
Alternating  current,  270 
Amenorrhma,  sitz  baths  in.  88 
Ampere,  the,  meaning  of  term.  269 

hour,  the,  meaning  of  term,  269 
Amemia,  climates  favourable  in  treat- 
ment of,  261 
diet  in,  440 
Animal  foods,  413 

classified  according  to  diges- 
tibility, 414 
Annu-ff's    establishment    for    koumiss 

cure,  456 
Annual  cure,  the,  necessity  for,  238 


Anorexia  nervosa,  rest  cure  in,  232 
Antineuritic    vitamin    (water-soluble 

vitamin  B),  417 
Antipyretic  effect  of  trunk  compresses, 

120 

value  of  packs,  124,  125 
Antiscorbutic  vitamin  (water-soluble 

vitamin  C),  417 
Apples,  composition  of,  413 
Arm,  active  and  forced  rotation  of, 

by  mechanotherapy,  176 
bath,  79 

circumduction   of,   by   mechano- 
therapy, 176 

Arms,    lowering    of,    with    flexion    of 

forearms,  by  mechanotherapy,  178 

Arterio-sclerosis,  Bergonie  treatment 

for,  406 
climates  favourable  in  treatment 

of,  261,  262 
diet  in,  441 
Arthritis,  rheumatoid,  diet  in,  445 

effects   of   luminous   radiant 

heat  baths  on,  15 
fango  baths  in  treatment  of, 

148 

Asparagus,  composition  of,  412 
Asthma,      climates      favourable      in 

treatment  of,  262 
Athermanous  bodies,  6 
Auto-condensation  in  high-frequency 

treatment,  370 
Auto-conduction    in    high  -  frequency 

treatment,  371 

Autonome  or  gas-mercury  interrupter, 
365,  360 

Back  laving  in  sitz  bath,  92 
massage  of,  163 
spouting  in  sitz  bath,  92 
Bandage,  abdominal,  120 
Banting  system  of  diet,  449-451 
Barker  vibrator,  170 
Barley-meal,  composition  of,  412 
Barley  soup,  composition  of,  412 
Baruch's  test  for  reactive  capacity,  53 
Baths,  arm,  79 


468 


INDEX 


469 


Baths,  brine,  151 
electric  light,  39 
foot,  79 

full  or  shallow,  95 
half,  93 
hand,  82 
head,  82 
hot-air,  2 

hydro-electric,  general,  347 
leg,  83 

medicated,  151 
Nauheim,  133 
partial  and  general,  technique  of, 

79 
peat,  fango  and  other  medicated, 

142,  152 
plunge,  94 
sand,  149 

Schnee,  four-cell.  344 
sitz,  84 

steam  cabinet,  24 
sun,  35 
taking  of,  general  considerations, 

77 

general  precautions,  78 
Turkish,  26,  28,  30 
use  of  electric  currents  in,  pre- 
cautions necessary,  323 
whirlpool,  109-112  ' 
Battery,  electric  current  derived  from, 

270.     See  also  under  Electric 
galvanic,  270 
medical,    for    electro  therapeutic 

work,  280 

Beans,  composition  of,  412 
Beef,  composition  of,  411 
Beef-tea,  composition  of,  412 
Beer,  composition  of,  412 
Bergonie  chair,  402 
treatment,  397 

coil  used  in,  398 

duration   and   frequency    of 

seances,  403 
electrodes  used  in,  402 
in  arteriosclerosis,  406 
in  cardiac  disease,  407 
in  metabolic  disorders,  404 
in  obesity,  405 
in  vasomotor  disorders,  405 
method  of  application  in,  401 
metronome  used  in,  398 
switchboard  used  in,  400,  401 
Berthe  apparatus,  31 
Beverages,  alcoholic,  421 

percentage  of  alcohol  in,  422 
composition  of,  412 
tea  and  coffee  as,  419,  420 
Bisserie's  adjustable  handle  for  high- 
frequency  treatment,  371,  373 
Blood,     constitution     of,     effects     of 
hydrotherapeutic  applications  on,  57 


i   Blood-pressure,  effects  of  hot  and  cold 

applications  on,  59 
effects     of    high-frequency     cur- 
rents on,  374,  375 
increase  of,  during  exercise,  191 
Body,   effects  of  general  application 

of  heat  and  cold  on,  52 
of  local  application  of  heat 

and  cold  on,  51 
heat  regulation  of,  54 
temperature,  effects  of  hot  baths 

on,  60 
Borderel   Zander   apparatus   for  me- 

chanotherapy,  176 
Bran  poultices,  129 
Bread  poultices,  128 
Bright' s  disease,  diet  in,  439 

whey  cure  in,  456 
Brine  baths,  151 
British  Isles,  climate  of,  features  of. 

259,  260 
Bronchial  catarrh,  climates  favourable 

to  treatment  of,  262 
Bronchitis,    climates    favourable    to 

treatment  of,  262 
Bruce-Sutherland  system  of  medical 

gymnastics,  200-230 
Bruises,  effects  of  luminous  radiant 

heat  baths  on,  14 
Butter,  composition  of,  411,  415 
Buttermilk,  composition  of,  411,  415 

Caloric  value  of  fat,  carbohydrate,  and 

albumin,  409 

of  food,  daily,  of  average 
man,  Van  Noorden's 
figures,  409 

"Calorie,"  definition  of  term,  409 
Calories,  percentage  of,  in  cereals  and 

vegetables,  412 
in  daily  products,  411 
in  fish,  413 

in  meats  and  game,  411 
in  soups  and  beverages,  412 
Carbohydrates,  caloric  value  of,  409 
in  diabetes,  464 
percentage    of,    in     cereals     and 

vegetables,  412 
in  dairy  products,  411 
in  fish,  413 
in  fruits,  413 
in  meats  and  game,  411 
in  soups  and  beverages,  412 
vegetable  foods  rich  in,  415 
Cardiac    dulness,   effect   of   Nauheim 

baths  on,  136 

disease,     tiee  Heart  disease 
Cardio-vascular     system,     effects     of 
hydrotherapeutic  application  son,  57 
Carp,  composition  of,  413 
Carrots,  composition  of,  412 


470        MANUAL  OF  PHYSIO-THERAPEUTICS 


Casein  foods,  462 
Cataphoresis.     See  lonization 
Cauliflower,  composition  of,  412 
Caviare,  composition  of,  413 
Cells,  dry,  271 

Leclanche,  270,  271 

types  of,  271 

wet,  270 

Cereals,  composition  of,  412 
Chapman's  spinal  ice-bag,  131 
Cheese,  composition  of,  411,  415 
Chest  compresses,  118 

massage  of,  163 
Chestnuts,  composition  of,  413 
China    tea    preferable    to    Indian    or 

Ceylon  tea,  419,  420 
Chlorosis,     climates     favourable     to 

treatment  of,  261 
Circulatory    organs,    effects    of    Nau- 

heim  baths  and  exercises  on,  135 
Climate,   choice   of,  in  treatment   of 
disease,  rules  for,  258,  259 

diseases  influenced  by,  261 

factor  of,  in   open-air  sanatoria 
for  consumption,  253,  264 

factors  in,  257 

composition  of  the  air,  257 

of  the  British  Isles,  features  of, 
259,  260 

varieties  of,  256 
Climatic  treatment,  255 

diseases  influenced  by,  261 
Coffee,  419 

composition  of,  412 
Coil  for  high-frequency  treatment,  368 

induction.     See  under  Induction 

used  in  Bergonie  treatment,  398 
Cold,  application  of,  effects  on  blood- 
pressure.  59 
on  pulse,  58 

general  application  of, effects  of,  52 

local  application  of.  effects  of,  51 

"rub,"  98 

Colitis,  mucous,  diet  in,  446 
Colon  douching,  technique  of,  74-76 
Commutator   for   a   four-cell    Schnee 

bath,  344 
Compresses,  chest,  118 

electrothermal,  121 

for  tonsils  and  pharynx,  1 1  7 

head, 115 

joint,  circular,  121 

technique  of,  113 

throat,  116 

trunk,  cooling.  1  1!) 

various,  in  use,  1 15 

wet,  113 
Condenser  in  X-ray  outfit,  354 

system  of  muscle-testing.  313 
Constipation,  diet  in,  435 

articles  allowed,  435 


Constipation,  articles  forbidden,  436 

general  directions,  436 
massage  in  treatment  of,  167 
sinusoidal  current  in,  343 
Consumption,  diet  in,  249-251 
open-air  sanatoria  for,  245 
See  also  under  Sanatoria 
Continuous  current,  270 
Convection,  5 
Cooking,  influence  of,  on  digestibility 

of  certain  foods,  417 
Cooling  trunk  compress,  119 
Copper  ionization,  396 
Coulomb,  the,  meaning  of  term,  269 
Cow's  milk,  composition  of,  411 
Cream,  composition  of,  411,  415 
cheese,  composition  of,  411 
Crookes's  tube,  349 
"Croyden"     preparation    for    Nau- 

heim  baths,  134 
"Cure"     establishments,     240.     See 

also  under  Hydropathic 
use  of  drugs  in,  242 
Current,  electric,  alternating,  270 

derived  from  a  battery,  270 
type  of  cells,  270, 271 
dynamo  and,  317 
faradic,  measurements  of  .298 
for     high-frequency    treat- 
ment, source  of,  363 
from    the    main,    safety    of 

using,  322 
the  multostat,  335 
use  of  thegalvanoset,330 
varieties  of,  319 
galvanic  collectors,  277 
crank  collectors,  278 
double  crank  collectors, 

.279 
nurse's      or      patient's 

battery,  276,  277 
density  of,  285 
Herschell  -  Dean      triphase 

generator,  340 
induced,  origin  of,  292 

primary  and  secondary, 
difference    in     effects 
produced  by,  295 
primary,  regulation   of, 

296 

regulation      and     mea- 
surement   of    current 
strength,  298 
secondary,  regulation  of, 

296 

strength  of,  295 
reversers  and  combiners,  329 
sinusoidal,  338 
the  switchboard,  324 
transformers  for,  static   and 
motor,  320,  321 


INDEX 


471 


Current,  use  of,  in  baths,  precautions 

necessary,  323 
Cutaneous    areas    reflexly    associated 

with  internal  parts,  63-65 

Dairy  products,  composition  of,  411 
percentage  of  albumin  in,  41 1 
calories  in,  411 
carbohydrates  in,  411 
fat  in,  411 

d'  Arsonval-Gaiffe  installation  for  high- 
frequency  treatment,  371 
"  Dae  oil,"  lubricant  for  use  in  mas- 
sage, 156 

Degeneration,  reaction  of,  306 
Da  Watteville  commutator  in  switch- 
board for  electric  current,  328 
Diabstes,  Allen  treatment  of,  465-467 
climates  favourable  to  treat- 
ment of,  262 
diet  in,  463,  464 
Diarrhoea,  diet  in,  437 
Diathermanous  bodies,  6 
Diathermy,  376 

apparatus  for,  331 

electrodes,  3S2 

"  Limpet"  aseptic  rubber  belts  in, 

379 

method  of  application,  382 
therapeutic  applications  of,  382 
Diet,  dried  milks  and  casein  foods,  462 
during  rest  cure,  234,  235 
in  diabetes,  463,  464 
in  disease,  431 

Hutchison's  rules  for,  431 
in  acute  gastritis,  433 
in  amemia,  440 
in  arterio-sclerosis,  441 
in  chronic  cardiac  disease,  443 
in  chronic  gastritis,  433 
in  chronic  rheumatism,  444 
in  constipation,  435 
in  diarrhoea,  437 
in  gastric  disease  and  insuffi- 
ciency, 432 

in  gastric  neurasthenia,  434 
in  gastric  ulcer,  434 
in    gastric    myasthenia    and 
dilatation  of  stomach,  434 
in  gout,  437-439 
in  hyperchlorhydria,  433 
in  mucous  colitis,  446 
in  obesity,  447,  448 
in   renal   disease   and   albu- 

minuria,  439,  440 
in  rheumatoid  arthritis,  445 
in  health,  425 

digestible  foods,  424 
factor  of  metabolic  idiosyn- 
crasy, 426,  428 
in  childhood,  429 


Diet  in  health  (continued) — 

indigestible  foods,  424 
in  old  age,  429 
seasonal    and     climatic    in- 
fluences, 430 

in    open-air   treatment   for   con- 
sumption, 249-251 
in  the  individual,  424 
in     the     treatment     of     disease, 
general    principles    and    com- 
position of  food,  408 
mixed     vegetable     and     animal, 

advantages  of,  408,  409 
the  Banting  system,  449-451 
the  grape  cure,  459 
the  koumiss  cure,  456-458 
the  milk  cure,  452-455 
the  Salisbury  system,  451,  452 
the  soured  milk,  460 
the  whey  cure,  455,  456 
Dietetics,  408 
Digestibility    of    foods,    influence    of 

cooking  on,  417 
relative,  422,  423 
Digestible  foods,  424 
Digestion,  gastric  time-table  for,  423 
Douche  and  needle  bath,  combined, 

102 
Douches,  99-109 

Aix,  103,  104,  105 
filiform,  102 
horizontal,  100 
massage,  104 
needle,  102 
percussion,  101 
rain,  102 
Scotch,  101,  109 
therapeutic,  indications  for,  103 
Vichy  massage,  105 
vaginal,  71 
Douching,  of  colon,  technique  of,  74- 

76 
vaginal,  71 

Doumer's  rectal  electrode  for  treat- 
ment of  haemorrhoids,  372 
Dowsing     radiant     heat     apparatus, 

forms  of,  16-20 
Dried  milks,  462 
Drip  sheet,  96-98 
Dropsy,  diet  in,  439 
Drugs,  use  of,  in   "cure"   establish- 
ment*. 242 
Dry  heat,  forms  of,  2 

pack, 124 

Du  Bois  Raymond's  coil,  298 
Duck,  composition  of,  411 
Dynamo,  the,  parts  of,  317 
Dvspepsia,  massage  in  treatment  of, 

167 

varieties  of,  climates  favourable 
in  treatment  of,  262,  263 


472        MANUAL  OF  PHYSIO-THERAPEUTICS 


Ear,  disease  of,  climates  favourable  in 

treatment  of,  263 
Eczema,  chronic,  climates  favourable 

in  treatment  of,  263 
Effleurage,  or  stroking,  in  massage,  157 
Effleuve     effects    in     high-frequency 

treatment,  367,  368 
Eggs,  composition  of,  411 
Einhorn's   tables   of    composition    of 

common  articles  of  food,  411 
Electric    batteries,    failure    to    work, 

causes  of,  286 
galvanic   tests  for  polarity, 

283 

current.     See  under  Current 
light  bath,  39 

indications  for,  45 
physiological  action,  42 
precautions     necessary, 

40 

therapeutic  effects,  44 
compared  with  sunlight,  39 
massage,  283,  312 
sweating  mattress,  125 
thermophore,  121 
Electrical  examination  of  muscles  and 

nerves,  302 
units,  269 

the  ampere,  269 
hour,  269 
the  coulomb,  269 
the  farad,  269 
the  Henry,  269 
the  microfarad,  269 
the  ohm,  269 
the  volt,  269 
the  watt,  269 
Electrodes,  301 

diathermy,  381 

for  ionization,  393 

types  of,  281,  282 

used  in  Bergonie  treatment,  402 

vacuum,       for       high-frequency 

treatment,  371 
Electro-therapeutics,  267 
accumulators,  272-275 
Bergonie  treatment,  397 
current  from  the  main,  319 
density  of  current,  285 
diathermy,  376 

effects  of  galvanism  on  skin,  284 
electrical  units,  269 
high-frequency     and     sinusoidal 

treatment,  363 
historical  summary,  267,  268 
ionization,  389 
medical  battery  for,  280 
sinusoidal  currents,  338 
static  machine,  383 
the  dynamo,  317 
the  four-cell  bath,  344 


Electro-therapeutics  (continued) — 

the  galvanoset,  330 

the       Herschell-Dean       triphase 
generator,  340 

the  multostat,  335 

the  switchboard,  324 

types  of  electrodes,  281,  282 
Electrothermal  compress,  121 
Epistaxis,  foot  bath  for,  82 
Exercise,  muscular.     See  under  Mus- 
cular 

Fango  baths,  142 

action  of,  145 
reaction  after,  145 
temperature  and  duration  of, 

144 
therapeutic   indications   for, 

147 

chemical  analysis  of,  143 
L)i  Battaglia,  143 
Farad,  the,  meaning  of  term,  269 
Faradic  battery,  types  of,  300 

contraction  of  muscle,  testing  for, 

303 

Faradiset,  the,  332 
Faradism,  287 

differences  in  effects  produced  by 
primary    and    secondary    cur- 
rents. 295 
failure  of  induction  coil  to  work, 

301,  302 
measurement  of  faradic  currents, 

299 

method  of  application,  309 
origin  of  induced  currents,  262 
primary  and  secondary  currents, 

application  of,  310 
currents,  293 
regulation   and  measurement   of 

current  strength,  298 
of  primary  currents,  296 
of  secondary  current,  296 
self-induction  —  extra      currents. 

292 

strength  of  induction  current,  295 
the  induction  coil,  288 
Faradization,  apparatus  for,  299 
general,  technique  of,  310,  311 
therapeutic    indications    for, 

313 
Fat.  caloric  value  of,  409 

percentage    of,    in    cereals    and 

vegetables,  412 
in  dairy  products,  41 1 
in  fish,  413 
in  fruits,  413 
in  meats  and  game,  411 
in  soups  and  beverages.  412 
Fatigue  after  exercise,  193 
Fat-soluble  vitamin  A,  416 


INDEX 


473 


Feeding.     See  Diet 
Fibrositis,  chronic,  climates    favour- 
able in  treatment  of,  263 
Filiform  douche,  102 
Fingers,  flexion  and  extension  of,  by 

mechanotherapy,  182 
Fischer    Kiefer    COg    generator    for 

Nauheim  bath,  141 
Fish,  composition  of,  413 
Fomentations,  126,  127 
Food,  common  articles  of,  composition 

of,  411 

composition  of,  408 
factor  in  medical  gymnastics,  197, 

198 
of    metabolic    idiosyncrasy, 

426,  428 

heat  unit  or  calorie  in,  409 
yarious  kinds  of,  caloric  value  of. 

409 

vitamins  in,  416 
Foods,  animal,  413 

classified  accordins  to  diges- 
tibility, 414 
casein,  462 
containing  purin,  426 
cooking  of,  influence  on  digesti- 
bility of,  417 
digestible,  424 
indigestible.  424 

percentage  of  iron  in  (table),  441 
relative  digestibility,  422,  423 
various,  percentage  composition 

of,  416 
vegetable,  415 

rich  in  carbohydrates,  415 

in  proteids,  415 
Food-stuffs,  relation  of,  to  physiology 

of  muscular  exercise,  189 
Foot  bath,  alternate  hot  and  cold,  80 
cold,  79 
hot,  80 
mustard,  80 

circumduction   of,   by   mechano- 
therapy, 186 
Forearm,  flexion  and  extension  of,  by 

mechanotherapy,  179 
pronation  and  supination  of,  by 

mechanotherapy,  181 
Four-cell  bath,  344     *  . 
Friction  massage,  159 
Fruits,  composition  of,  413 
Full  or  shallow  bath,  95 
"  Fulling,"  movement  of,  in  massage, 

158 

Fuse  in  switchboard  for  electric  cur- 
rent, 325 

Gaiffe's  or  Bondel's  gas-mercury 
break  in  high-frequency  treatment, 
advantages  of,  363 


Galvanic  testing  of  muscle,  304 
Galvanism,  accumulators,  272-275 
central,  application  of,  309 
current  collectors,  278 
density  of  current,  285 
effects  on  skin,  284 
electrical  units,  269 
general,  application  of,  309 
medical  battery  for,  280 
types  of  electrodes.  281,  282 
use  of,  308 
Galvano-faradism,  267 

reaction  of  degeneration,  306 
Galvano-faradization,    technique    of, 

313 
Galvanometer     on     switchboard    for 

electric  current,  327 
Galvanoset,  four-way  connectors  for, 

335 

instructions  for  using,  334 
use  of,  330 

Game,  composition  of,  411 
Gastric   catarrh   and  gastric   neuras- 
thenia, climates  favourable  in 
treatment  of,  263 
digestion,  time-table  for,  423 
disease  and  insufficiency,  diet  in, 

432 

myasthenia,  diet  in,  434 
neurasthenia,  diet  in,  434 
ulcer,  diet  in,  434 
Gastritis,  acute,  diet  in,  433 

chronic,  diet  in,  433 
Geissler  tube,  349 
Gluten  in  bread,  415 
Glycosuria,       alimentary,       climates 

favourable  in  treatment  of,  262 
Gout,    climates    favourable  in  treat- 
ment of,  263 
diet  in,  437-439 
effects  of  luminous  radiant  heat 

baths  on,  14 

fango  baths  in  treatment  of,  149 
lithium  ionization  for,  397 
Grape  cure,  the,  459 
Grapes,  composition  of,  413 
Greville    electro-thermic    generators, 

21 
Gymnastics,  medical,  195  et  sen. 

Bruce  -  Sutherland     system, 
200-230 

"Hacking"  in  massage,  160 
Half  baths,  93 

indications  for,  94 

value    of,    in    typhoid    and 

other  fevers,  94 
Ham,  composition  of,  411 
Hand  bath,  82 

circumduction  of,   by   mechano- 
therapy, 1^2 


474        MANUAL  OF  PHYSIO-THERAPEUTICS 


Hare,  composition  of,  411 
Headache,  chronic,  climates  favour- 
able in  treatment  of,  264 
foot  and  head  baths  for,  80,  82 
Head  bath,  82 

compress,  115 
Health,  diet  in,  424 
Heart  disease,  Bergonie  treatment  in, 

407 

chronic,  diet  in,  443 
climates        favourable        in 

treatment  of,  265 
effect  of  muscular  exercise  on,  190 
effects  of  hydrotherapy  on,  57 
of  Nauheim  baths  on,  135 
Heat,  application  of,  effect  on  blood- 
pressure,  59 
on  pulse,  58 

general  indications  for,  61 
dry,  forms  of,  2 
exposure  to,  toleration  of,  61 
general  application  of,  effects  of, 

52 

local  application  of,  effects  of,  51 
moist,  temperatures  of,  2 
physiological  effects  of,  54 
radiant,  luminous,  3 
regulationof  bodytemperature,  54 
unit  "  calorie,"  409 
Hedgehog  pattern  effleuve  brush  for 

high-frequency  treatment,  372 
Henry,  the  (electrical  unit),  meaning 

of  term,  269 
Hernaman  Johnson  condenser  system 

for  muscle  testing,  313,  315 
Herschell-Dean     triphase     generator, 

340 

High-frequency  treatment,  363 
auto-condensation,  370 
auto-conduction  in,  371 
Bergonie  treatment,  397 
coil  for,  368 

d '  Arsonval  -  Gaiff e     installa- 
tion for,  371 
diathermy,  376 
effleuve  effects  in,  367 
ionization,  389 
measuring  the  current  in,  372 
methods  of  application,  370 
source  of  current  for,  363 
stand  with  oil  condenser  and 
milliampere meter  for,  369 
static  machine,  383,  387 
therapeutic  value  of,  373-376 
types  of  electrodes,  372 
vacuum  electrodes  for,  371 
Honey,  composition  of,  413 
Horizontal  douche,  100 
Hot-air  bath,  2 

cabinet  bath,  22 

indications  for,  24 


Hot-wire  milliamperemeter,  373 
Humidity,  257 

Hutchison's  rules  for  dietetic   treat- 
ment, 431 

Hydro-electric  bath,  general,  347 
Hydropathic  institutions,  annual  cure 

at,  240,  241 
types  of,  240 
Hydrotherapeutic   applications,  basis 

of,  61 
function  of  nerve  reflexes  in, 

62 
general  effects  of,  55 

on  blood  constitu- 
tion, 57 
on    cardio-vascular 

system,  57 
on  internal  organs, 

60 

on  metabolism,  55 
on      muscles      and 
muscular    tissue, 
56 
on  nervous  system, 

56 

on  respiration,  59 
on  skin,  56 
procedures,  physiological  reaction 

after,  52 
Hydrotherapy,  general  principles  of, 

49 
Hyperaemia  induced   by  compresses, 

115 
Hyperchlorhydria,  diet  in,  433 


Ice-bag,  131 
Ice-rubbing,  231 
Indigestible  foods,  424 
Indoor  sun  bath,  35 
Induced  current,  origin  of,  292 
Induction  coil,  288 

differences    in    effects    pro- 
duced   by    primary    and 
secondary  currents,  295 
failure   to   work,   causes   of, 

301,  302 

measurement  of  faradic  cur- 
rents, 299 

Neef's    hammer    and    inter- 
rupter in,  290 
origin  of  current,  292 
primary  currents,  293 
regulation  and  measurement 
of    current    strength , 
298 

of  primary  currents,  296 
of     secondary     current, 

296 

self  -  induction,    extra    cur- 
rents, 292 


INDEX 


475 


Insomnia,     climates     favourable     in 

treatment  of,  264 
massage  in  treatment  of,  168 
Internal  organs,  cutaneous  areas  re- 
Hexly  associated  with,  63- 
65 
effects    of   liydrotherapeutic 

applications  on,  60 
Intoxicating  beverages,  percentage  of 

alcohol  in,  422 
lonization,  389 
copper,  396 
electrodes  for,  393 
lithium,  397 
magnesium,  397 
preparation  of  skin  before,  395 
salicylic  acid,  397 
sodium  chloride,  397 
therapeutic  uses  of,  396,  397 
zinc,  396 

Iontophoresis.     See  lonization 
Irrigation,  rectal,  1'2 
urethral,  73 
vaginal,  71 

"  Isotonic    balance"    of    blood    and 
tissues,  113 

Joint  compresses,  circular,  121 
Joints,     affections     of,     massage     in 
treatment  of,  168 

Kellogg  compress,  117 

Kellogg's  nozzle  for  percussion  douche, 

101 

Kidneys,  diseases  of,  climates  favour- 
able in  treatment  of,  261 
diet  in,  439,  440 
electric  light  bath  in,  46 
Kneading,  or  petrissage,  in  massage, 

157 
Knee,   flexion  and   extension   of,   by 

mechanotherapy,  185 
Koumiss,  analysis  of,  457 
artificial,  457 
composition  of,  411 
cure,  the,  456-458 

relative  composition  of 
several  strengths  of  kou- 
miss, 457 

"  Lactobacilline,"  461 

Lamps    on    switchboard   for    electric 

current,  325 
Leclanche  cell  for  electro-therapeutic 

work,  270-272 
Leg  bath,  83 

sweating,  83 
extension  of,  by  mechanotherapy, 

183 

flexion    of,    by    mechanotherapy, 
184 


Legumin  in  vegetable  foods,  415 
Leube's    meat    solution,  composition 

of,  412 

Leucocytosis     induced      by     hydro- 
therapy,  57 

Leucodescent  lamp,  47,  48 
Lewis    Jones    condenser    system    for 

muscle  testing,  313,  314 
sledge     coil     with     separate 

battery,  301 

Light,   action   of,  on   metabolic  pro- 
cesses, 33 

therapeutic  application  of,  34 
Limpet  aseptic  rubber  belts,  379 
Linseed  poultices,  128 
Lithium  ionization,  397 
Liver  pack,  129 

Lubricants,  use  of,  in  massage,  156 
Luminous  radiant  heat,  3 

appliances  for  diffusion 
in  an  enclosed 
space,  18 

for  direct  radiation 
without  heating 
surrounding  at- 
mosphere, 17 
for  utilization  of 
certain  deter- 
mined radiations 
to  exclusion  of 
others,  20 

penetrative    powers 
greater      than      non- 
luminous,   12 
physical  facts  regarding, 

3-7 
physiological  action  of, 

7-16 

sedative  action  of,  9 
temperatures  used  in,  7 
therapeutic  indications, 
13 

Magnesium  ionization,  397 
Malt  extract,  composition  of,  412 
Manipulative  treatment,  173 
Massage,  154 

centripetal  direction  of  manipu- 
lations, 156 

conditions  not  benefited  by,  169 
douche,  104 
duration  of  seance,  156 
during  rest  cure,  236 
effects  of,  general,  166 
effleurage,  or  stroking,  157 
electric,    wristlet    electrode    foi, 

283 

friction,  159 

general,  position  for,  156 
rules  for,  156 
technique  of,  161 


476       MANUAL  OF  PHYSIO-THERAPEUTICS 


Massage,  hacking,  160 
of  abdomen,  165 
of  back,  163 
of  chest,  163 
of  stomach,  163 
patient's  clothing  during,  156 
petrissage,  or  kneading,  157 
position  of  limbs  for,  156 
relaxation  of  muscles  necessary 

in,  156 

tapotement,  or  tapping,  in,  158 
therapeutic  indications  for,  167 
use  of  lubricants  in,  156 
vibration,  159 
Massotherapy,  154-172 
Mattress,  electric  sweating,  125 
Meat  broth,  composition  of,  412 

juice,  composition  of,  412 
Meats,  various,  composition  of,  411 
Mechanotherapy,  176 

active  and  forced  rotation  of  the 

arm,  176 
Borderel  Zander  apparatus  for, 

176 

circumduction  of  arm,  176 
of  foot,  186 
of  hand,  182 

extension  of  thigh  and  leg,  183 
flexion  and  extension  of  fingers, 

182 

of  forearm,  179 
of  knee,  185 
of  wrists,  178 
of  leg  and  thigh,  184 
lowering  of  arms  with  flexion  of 

forearms,  178 
other  forms  of  exercise,  187 
pronation  and  supination  of  fore- 
arm, 181 
Medical  battery  for  electro-therapeutic 

work,  280 
gymnastics,  195-199 

Bruce  -  Sutherland     system, 

200-230 

Medicated  baths,  151 
Menstrual  disorders,  baths  in,  88 
Metabolic   processes,   action   of   light 

on,  33 
Metabolism,    disorders    of,    Bergonie 

treatment  for,  404 
effect  of  hydrotherapeutic  appli- 
cations on,  55 

Metchnikoff's  soured  milk  diet,  460 
Metronome  used   in    Bergonie  treat- 
ment, 398 

Microfarad,  the,  meaning  of  term,  269 
Milk,  articles  of  food  obtained  from, 

415 

composition  of,  411,  414 
cure,  the,  452-455 
dried,  462 


Milk  soup,  composition  of,  412 

soured,  diet  of,  460 
Milliamperemeter,  hot-wire,  373 

Moist  heat,  temperatures  of,  2 

Motor  transformers,  321 

Mouth,  administration  of  water  by, 

66 

Movements,  active,  175 
assistive,  175 
free,  175 
resistive,  176 
passive,  173,  174 
Mucous  colitis,  diet  in,  446 
Multostat,  the,  335 

advantage  of,  337 
Muscles,  effects    of  hydrotherapeutic 

applications  on,  56 
electrical  examination  of,  302 
excitation  of,  by  Bergonie  treat- 
ment, 397 
faradic    contraction    of,    testing 

for,  303 

galvanic  testing  of,  304 
Muscle-testing,  condenser  system  of, 

313 

Muscular  exercise,  fatigue  after,  193 
good  results  of,  193 
physiology  of,  187 

relation    of    food-stuffs 

to,  189 

relation  of  oxygen  con- 
sumption to,  189 
Mustard  applications,  129 
cloth,  129 
foot  bath,  80 
plaster,  129 

Mutton,  composition  of,  411 
Myalgia,  massage  in  treatment  of,  168 
Myasthenia,  gastric,  diet  in,  434 

Nauheim  baths,  133 

and  exercises,  effects  on  cir- 
culatory organs,  135 
artificial,    preparations    for, 

133,  134 
effects    on    cardiac    dulness, 

136 

technique  of,  134 
value  of,  136 
springs  at,  chemical  contents  of, 

133 
Needle  and   douche   bath   combined, 

102 
Nephritis,  effects  of  luminous  radiant 

heat  baths  on,  15 
Neptune's  girdle,  120 
Nerve,  reaction  of  degeneration,  306 
reflexes,   function   of,   in  hydro- 
therapeutic  applications,  62 
Nerves,     electrical     examination     of, 
302 


INDEX 


477 


Nervous  affections,  massage  in  treat- 
ment of,  168 

"  Nervous  cough,"   climates  favour- 
able in  treatment  of,  262 
Nervous    system,    effects    of    hydro- 
therapeutic  applications  on,  56 
Neuralgia,     climates     favourable     in 

treatment  of,  265 
Neurasthenia,  central  galvanism  for, 

309 

climates     favourable     in     treat- 
ment of,  265 
gastric,  diet  in,  434 
high-frequency  current  in  treat- 
ment of,  374 
Neuritis,  fango  baths  in  treatment  of, 

148 

massage  in  treatment  of,  168 
Neuroses,  abdominal  and  pelvic,  fango 
baths  in  treatment  of,  149 

Oatmeal,  composition  of,  412 
Obesity,  Bergonie  treatment  for,  405 
climates  favourable  in  treatment 

of,  266 

diet  in,  447,  448 
Salisbury  diet  system  for,  451 
value  of  electric  light   baths   in 

treatment  of,  45 
Ohm,  the,  meaning  of  term,  269 
Oil  rub,  the,  231 
Open-air  sanatoria  for  consumption, 

etc.,  245 

Osmo-regulator  for  X-ray  tubes,  357 
Oudin's  resonator  and  oil  condenser, 

364,  367,  368 
Oxygen  consumption  during  exercise, 

increase  of,  191 
in  relation  to  physiology  of 

muscular  exercise,  189 
Oysters,  composition  of,  413 

Pack,  dry,  124 
liver,  129 
wet,  122 

Packs,  therapeutic  indications  for,  125 

Pain,  visceral,  areas  of  skin  reflexly 
associated  with,  65 

"  Partial  rub,"  98 

Passive  movements,  173,  174 

Peaches,  composition  of,  413 

Pears,  composition  of,  413 

Peat  baths,  142,  152 

Percussion  douche,  101 

Petrissage,  or  kneading,  ir^massage,  157 

Pharynx,  compress  for,  117 

Phlebitis,  effects  of  luminous  radiant 
heat  baths  on,  15 

Phototherapy,  33 

Physiological    reaction    after    hydro- 
therapeutic  procedures,  52 


Physiology  of  muscular  exercise,  187 

Pickles,  composition  of,  412 

Pike,  composition  of,  413 

Plaster,  mustard,  129 

Plombieres  douche,  technique  of,  74- 
76 

Plums,  composition  of,  413 

Plunge  bath,  94 

Polvphase   switchboard   with   motor, 
342 

Pork,  composition  of,  411 

Porter,  composition  of,  412 

Potatoes,  composition  of,  412 

Poultices,  126,  128 

Poultry,  composition  of,  411 

Proteids,    vegetable    foods    rich    in, 
415 

Psychrophore,  73 

Pulse,  effects  of  cold  applications  on, 

58 

of  Dowsing  baths  on,  9 
of  drinking   cold   water  on, 

66 

of  heat  applications  on,  58 
of  Nauheim  baths  on,  137 

Purin  containing  food-stuffs,  426 

Radiant  heat,  definition  of,  4 

luminous,  3 

Radiation,  definition  of,  4 
Rain  douche,  102 
Reaction  of  degeneration,  306 

physiological,    after   hydrothera- 

peutic  procedures,  52 
Reactive  capacitv,  Baruclvs  test  for, 

53 
Rectum,  administration  of  water  bv, 

68 

irrigation  of,  72 
Respiration,    effects    of    hydrothera- 

peutic  applications  on,  59 
Rest  cure,  complete  rest  essential  in, 

233 

conditions   indicating   treat- 
ment by,  232,  233 
essential  factors  in,  232 
feeding  in,  234,  235 
isolation  of  patient  essential 

in,  234 

massage  during,  236 
metabolism  of  patient  during, 

236 

results  of,  237 
Rheostat,  shunt,  on  switchboard  for 

electric  current,  325 
Rheumatism,  chronic,  diet  in,  444 
effects  of  luminous  radiant  heat 

baths  on,  14 
fango  baths  in  treatment  of,  147, 

148 
ionization  in  treatment  of,  397 


478        MANUAL  OP  PHYSIO-THERAPEUTICS 


Rheumatoid  arthritis,  diet  in,  445 

effects  of  luminous  radiant 

heat  baths  on,  15 
fango  baths  in  treatment  of, 

148 
diseases,   climates  favourable   in 

treatment  of,  266 
Rice,  composition  of,  412 

pap,  composition  of,  412 
Ringworm,  copper  ionization  for,  3(J6 
Rodent  ulcer,  zinc  ionization  in  treat- 
ment of,  396 
Rubs,  231 

ice-rubbing,  231 
the  alcohol  rub,  231 
the  oil  rub,  231 
the  salt  glow  or  rub,  231 
Ruhrnkorff  induction  coil,  352,  353 
Rye  bread,  composition  of,  412 
flour,  composition  of,  412 

Sago,  composition  of,  412 
Sahli's  iron   ball,  substitute  for  ab- 
dominal massage,  166 
Salicylic  acid  ionization,  397 
Salisbury  diet  system,  451,  452 
Salmon,  composition  of,  413 
Salt  glow  or  rub,  231 

herring,  composition  of,  413 
Sanatoria,  open-air,  for  consumption, 

etc.,  245 

climatic  factor,  253,  264 
dietary  in,  249-251 
general  construction  of, 

253 

grounds  of,  253 
importance  of  rest  and 

exercise,  247 
routine  at,  246,  247 
selection  of  patients  for, 

246 
Sanatorium,  general  construction  of, 

251,  253 
Sand  baths,  149 
Schnee  bath,  four-cell,  344 

general  galvanism  with,  309 
Schott-Nauheim     exercises,     contra- 
indications to,  142 
summary  of  action,  139 
technique  of,  137,  138 
Sciatica,  effects  of  luminous  radiant 

heat  baths  on,  15 
ionization  in  treatment  of,  397 
massage  in  treatment  of,  168 
Scotch  douche,  101,  109 
Sea  voyage,  benefits  of,  243 

choice  of  route,  etc.,  impor- 
tant, 243 

Shellfish,  composition  of,  413 
Shot   bag,   substitute   for   abdominal 
massage,  166 


Shunt   rheostat    on    switchboard    for 

electric  current,  325 
Sinusoidal  currents,  338 

single-phase  and  polyphase, 

339 

three-phase  currents,  339 
triphase.   therapeutic   appli- 
cations of,  342,  343 
treatment,  363 
Sitz  baths,  therapeutic  indications  for, 

88 

varieties  of,  85-88 
»vith  back  laving,  92 

spouting,  92 
Skin   affections,   climates  favourable 

in  treatment  of,  263 
areas  of,  refiexly  associated  with 

internal  parts,  63,  64,  65 
effects  of  Dowsing  baths  on,  9 
of  galvanism  on,  284 
of  hydrotherapeutic  applica- 
tions on,  56 
preparation  of,  before  ionization, 

395 

Sledge  coil  for  faradic  current,  301 
Sodium  chloride  ionization,  397 
"  Sool-Bader,"  151 
Sound,  urethral,  cooling,  73 
Soups,  composition  of,  412 
Soured  milk  diet,  fhe,  460 
Spamer  faradic  battery,  300 
Spinach,  composition  of,  412 
Spinal  ice-bag,  131 
Sprains,  effects  of  luminous   radiant 

heat  baths  on,  14 
Starch  poultices,  129 
Static  machine,  383 

methods  of  using,  387 
positive  and  negative  poles 

in,  386 

with  six  vulcanite  plates,  385 
transformers,  320 
wave  currents,  389 
Steam    cabinet    bath,    duration    and 
physiological    effects, 
24,  25 

indications  for,  25 
Stimulants.     See  Alcohol 
Stomach,  dilatation  of,  diet  in,  434 
massage  of,  163 
See  also  under  Gastric 
Strawberries,  composition  of,  413 
Stroking,    or  effleurage,    in    massage, 

157 

Sugar-cane,  composition  of,  413 
Sun-baths,  indications  for,  38 
indoor,  35 

physiological  effects,  38 
open-air  and  arenarium,  35,  36 
Sunlight  compared  with  electric.  39 
various  ravs  in.  33 


INDEX 


479 


Sweating  leg  bath,  £3 

mattress,  electric,  125 
Sweetbread,  composition  of,  411 
Switchboard  for  electric  current,  324 
reversers  and  combiners, 

329 

the  De  Watteville  com- 
mutator, 328 
the  fuse,  325 
the  galvanometer,  327 
the  Tamps,  325 
the  shunt  rheostat,  325 
in  X-ray  outfit,  355 
used    in     Bergonie    treatment, 

400,  401 

Syringe,      gravity,      adjustable      for 
vaginal  douching,  71 

Tabes  dorsalis,  fango  baths  in  treat- 
ment of,  149 
Tapotement,  or  tapping,  in  massage, 

158 
Tapping,  or  tapotement,  in  massage, 

158 
Tea,  419 

abuse  of,  420 

China,    preferable   to    Indian   or 

Ceylon  tea,  419,  420 
composition  of,  412 
Temperature,  body,  effects  of  Dowsing 
bath  contrasted   with 
Turkish  bath,  11 
of  drinking    cold   water 

on,  66 

of  various  baths,  10,  49 
Tesla  transformer  for  high-frequency 

treatment,  369 

Thermic  flexibility  of  water,  50 
Thcrmogenesis,  54,  55 
Thermometric   equivalents,   table   of, 

10 

Thermophore,  electric,  121 
Thermotaxis,  54 
Thermotherapy,  history  of,  1 
Thigh,    extension    of,    by    mechano- 

therapy,  183 
flexion   of,   by   mechanotherapv, 

184 

Throat  compresses,  116 
Tinnitus,      climates     favourable      in 

treatment  of,  263 
Tonsils,  compress  for,  117 
Transformers     for     electric     current, 

static  and  motor,  320,  321 
Triphase  apparatus  for  direct  current 

main,  341 

Trunk  compress,  cooling,  119 
Tuberculosis,  diet  in,  249-251 
Turkish  bath,  26 

indications  for,  and  contra- 
indications, 30 


Turkish  bath,  physiological  action  of, 

29 

stages  of,  28 
technique  of,  28 
Typhoid  fever,  value  of  half  bath  in, 

94 
Tyrnauer  apparatus,  30 

Ulcer,  gastric,  diet  in,  434 

Uraemia,  diet  in,  439 

Urethra,  irrigation  of,  73 

Urethral  sound,  cooling,  73 

Uric-acid  diathesis,  value  of  electric 
light  baths  in  treatment  of,  45 

Urine,  volume  of,  increased  by  Dows- 
ing baths,  11 

Vacuum  electrodes  for  high-frequency 

treatment,  371 
Vaginal  douching,  71 
Vascular  areas,  relation  of  skin  areas 
to,  in  hvdrotherapeutic  applications, 
62-66  " 

Vasomotor  disorders,  Bergonie  treat- 
ment for,  405 
Veal,  composition  of,  411 
Vegetable  foods,  415 

rich  in  carbohj'drates,  415 

in  proteids,  415 

Vegetables,  composition  of,  412 
Venison,  composition  of,  411 
Vibration,    conditions    benefited    by, 

172 

effects  of,  172 
in  massage,  159 
mechanical,  devices  for,  170 
technique  of,  109,  170 
Vibrator  applicators.  171 
Vibrators,  mechanical,  various  foims 

of,  170 

Vichy  massage  douche,  105 
Visceral  pain,  cutaneous  areas  reflexly 

associated  with,  65 
Vitamins  in  food,  416 
Volt,  the,  meaning  of  term,  269 

Warts,    magnesium     ionization    for, 

397 

Water,    application    of,    to    body   at 
various  temperatures,  physio- 
logical action  of,  50 
changes  in,  at  various  tempera- 
tures, 50 

drinking  of,  effect  on  body  tem- 
perature, 66 

rapidity  of  absorption  of,  67 
heat-conducting  power  of,  49,  50 
internal  administration  of,  by 

mouth,  66-71 
by  rectum.  68-71 
thermic  flexibility  of,  50 


480        MANUAL  OF  PHYSIO-THERAPEUTICS 

Water-soluble  vitamin  B,  417  X-rav  coil,  353 

vitamin  C,  417  outfit,  352 

Watt,  the,  meaning  of  term,  269  the  coil,  353 

Weir  Mitchell  treatment,  232,  237  the  condenser,  354 

Wet  compress,  113  the  switchboard,  355 

pack,  122  the  tube,  356 

Wheat  flour,  composition  of,  412  working  of,  359 

Wheaten      bread,      composition     of,  tubes,  356 

412  hard  and  soft,  356 

Whey,  composition  of,  411,  415  range  of  currents  used  for, 

cure,  the,  455-456  360 

Whirlpool  bath,  109-112  reverse  currents  in,  361      , 

Winternitz's    urethral    psychrophore,  X  rays,  production  of,  348,  351 

73 

Wrists,  flexion  and  extension  of,  by  Zinc  ionization,  394 

mechanotherapy,  178  Zwieback,  composition  of,  412 


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